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Contact and patient ordering form

You can use this template for scheduling of your appointment or sending some other message to us.
 
Name: *
E-mail: *
Phone: *
Please use phone number in international format: +421xxxxxxxxx
 
Please state two dates of the appointment which suites you the best.
1st appointment:
2nd appointment:
 
Your message, and short description of your medical problem:
 
You can also schedule your appointment by phone: +421 - 33 - 775 2001.