Holiday dialysis application form

If you wish to have dialysis with us while on holiday, please complete this form.

Gender

Male

Female

First name *

Surname *

Date of birth *

Street address *

Postcode *

City *

Country *

E-mail adress *

Telephone number *

Mobile telephone number

BSN (Citizen Service Number) *

I would like to have dialysis in the Dianet dialysis centre in:

In the following period: from *

Until *

Number of dialysis per week *

Desired time of day:

morning (from 9.30am)

afternoon (from 4pm)

evening (from 11pm. NB places are limited)

Do you have a European Health Insurance card?

Other remarks