Title: |
Sir Mrs. * |
First given name: |
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Surname: |
* |
Street, house number: |
* |
Postcode City: |
* |
Birthday: |
*
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E-mail: |
* |
Phone: |
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Health Insurance |
|
Aid: |
Yes
No
|
Where do you have pain ?: |
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
Left
right
|
Without presentation of your radiology report by PDF or fax, your request can not be answered. Please make a note of the keyword "Online request" on the fax.
|
PDF file
|
Send fax to 089/45600890. The report was edited on:
|
No documents available
|
- How long have you been in pain?
- What makes the pain worse?
- How do you ease the pain?
- What treatments have been used so far performed
Your message: *
|
Terminwunsch: |
|
Required fields: |
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I hereby accept the data protection conditions and agree to the transmission and electronic processing of my data transmitted in the context of medical treatment. * |
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