Request an Appointment

To schedule an appointment, please call us at telephone number 088-0088444 or complete the online form below. An Asterisk means the field is required.

One of our appointment schedulers will respond to your request as soon as possible.  

Please don’t use this form if you have an urgent medical problem or to re-schedule an existing appointment. 

Your complaint

Which joint*

At what side is the joint located?*
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Description of your complaint

General practitioner and insurance

Insurance company*

Name General practitioner *

Contact information

Title*

 Sir

 Mrs

Initials*

Surname*

Maiden name

Day of birth*
 dd-mm-yyyy

E-mail adress*

Home phone / Cell phone*

Adress information

Street

House number*

Zip code*

Remarks

Remarks
Please fill in additional information concerning your request. This form is not suitable for medical questions.  Max. 160 icons