| |
Title |
|
First
name and surname* |
|
Street
and number* |
|
Postal
code and place* |
|
Telephone
(incl. area code) |
|
Telefax
(incl. area code) |
|
Cell
phone |
|
e-mail |
|
|
These details * must be given.
We require this information in order to process
your enquiry.
|
| I
have the following illnesses / complaints: |
| |
|
| I became
aware of the hospital MIC Klinik Berlin, through… |
An article in... |
|
| A patient who received treatment in
the hospital |
| The internet |
|
|
