Accommodation registration

Patient

Last name:
First name:
Date of birth (dd/mm/yy):
Citizenship:
E-mail:
Concerted treatment date:
Accompanying persons number:
Arrival date:	time
Departure date:	time

Accommodation:

At the International Clinic	room type:
Ambulatory treatment

Comments:
Contact person:
E-mail:
Contact phone:

Please enter here the word as displayed in the picture. This is to prevent spamming. If you can't read the word, click here.