New patient – appointment

If you are a new patient and you would like to make an appointment, please fill out the information bellow.
We will contact you within 5 working days.

As soon as we confirm the date of your visit, download and fill in the questionnaire here.
Please bring it with you to the initial examination.

Name and surname: *
Phone number: *
Personal identification number: *
Insurance company: *
E-mail: *
Attach a file (a copy of the recommendation + possible laboratory results): *
Přetáhněte soubory sem Procházet soubory
Street: *
City: *
House number: *
ZIP code: *
Alergies *
If the medications you are taking are not listed on the application form, please list them below:
Note:

I agree that the data provided in the questionnaire will be sent to the healthcare facility via a specially set up email address, and that this communication is secured by encryption. Further information about the processing of my personal data is available here.

SEND

Sledujte restrial

Získejte aktuální informace
z Vaší ordinace