Dialyse-Praxis Berlin Kreuzberg-Friedrichshain
Die Dialysepraxis in Berlin Oberbaum City
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Form For Announcing - Guest DialysisGerman version
Dialysis patients, who are guests in Berlin, use this form please to announce here to guest dialysis. As soon as possible we will contact You to arrange dialysis times You wish.
Of course You can call us if You have any questions: +49 (0)30 200 568-0


Personal data


First Name, Name*


Road/No.*


ZIP Code/City*
/


Phone*


Fax*


eMail*


guest dialysis (days)* from to

days of dialysis:*

Mon Tue Wed Thu Fri Sat
daytimes:*

morning evening afternoon night

duration:* hours
Information health insurance company

Health insurance company


Your home-dialysis*


Name of your doctor*

Phone*


Fax*


required*
Hepatitis B positive negative
Hepatitis C positive negative
HIV positive negative

For questions and informations:



 * required informations download PDF to print
 
© 2004 - 2005 Dialysepraxis Kreuzberg-Friedrichshain - Tel: (030) 200568-0 - Fax: (030) 200 568-28 - @ eMail
German version