Patient Service Form

Contact's Info
Title :
Tel :
First Name :

Fax :

Last Name :
*Email :

Patient's Info
(*) Compulsory Field
Title :
First Name : *
Last Name : *

Sex : *

Date of Birth :
Nationality : *
Tel :
Fax :
Email : *

Address :

City :
Post Code :

Country of Residence : *

Remarks: *


Disclaimer Notice

Prices will be for rough planning purposes only to assist the patient in understanding the possible range of costs. Actual estimates for care cannot be accurately provided until the patient has been thoroughly examined by the DSH physician. The cost ranges provided are based upon our best understanding of the patient's condition at the time of contact and do not represent a minimum or maximum potential cost.


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