Holiday Dialysis Bulgaria

	• Home	• Dialysis	• Request	• Recreation	• Service	• Contact

Theodor Morkel
Phone + 49 - 214 - 86 92 558

D-51371 Leverkusen
Rüttersweg 97
Fax + 49 - 214 - 86 92 559
info@feriendialyse-bulgarien.com

Do you know someone who is interested on our dialysis facility?
Then recommend us!

To guarantee good dialysis service and the best medical care, we would like to ask you to fill in this registration form and send it back to us. The also necessary documents are ready for you.
Reference to the data security If within the InterNet you find the offer to submit personal data, then giving up these data is voluntary. We guarantee that the data are stored and used exclusively in the context of the legal regulations. The use of these data for other purposes is expressly forbidden.

Personal data		* the red marked fields please fill out

Title		First Name


Last Name*		Street Address*


ZIP or Postal Code/City*		Full Phone Number


E-Mail Address		Date of birth
		(DD.MM.YYYY)

The health insurance company

Name*		Street Address


ZIP/City		Full Phone Number


Fax		Insurance number


Center data

Home center		Street Address


ZIP/City		Full Phone Number


Fax


Medical data

Dialysis time (hour)
		morning afternoon evening

Travel data

Hotel Address		Travel time


Message