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PATIENT BOOKING ENQUIRY

Name, Forename(*)

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Street, Number(*)

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Zip code. Town (*)

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Phone/Fax

Phone(*)

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fax(*)

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Birthday(*)

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E-Mail(*)

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First dialysis treatment necessary on

Last treatment on my stay in Hurghada on

day/month/year(*)

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day/month/year(*)

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I prefer my treatments in the(*)

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The name of my current Hospital/clinic dialysis is(*)

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Zip code. Town (*)

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Street, Number(*)

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Phone(*)

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E-Mail

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The name of my Nephrologist is Dr.(*)

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My Insurance company is(*)

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My Insurance personal number or code is(*)

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I have the approval receipt of my insurance for the Hurghada dialysis treatments(*)

Yes

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I prefer to pay the treatment by(*)

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Kind of credit card(*)

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Pay attention: Credit card fees are at the expense of the cardholder. Debiting of the credit card will be on the daily exchange rate.

My last hospitalization was on day/month/year(*)

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I am dialysis patient since month/year(*)

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I am using(*)

double needle

single needle

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I will arrange for sending you the actual medical records including the Hepatitis B + C + MRSA + HIV screening and treatment sheets before my arrival in Hurghada by info@hurghada-arabia-dialysiscenter.com or by FAX: +2065-3540372

My Hotelreservation:

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From(*)

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person(s)(*)

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To(*)

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The name of my Hotel wil be

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I will check in day/month/year(*)

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**Costs per treatment 230.00 €. Doctors fee included

My questions/message/remarks

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CAPTCHA (*)

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The Dialysis Center

PATIENT BOOKING ENQUIRY