Anmeldung – Nierenzentrum Bremen Süd

AnmeldungHB2022-01-05T15:21:01+01:00

ÖFFNUNGSZEITEN

Mo, Mi & Fr	7:00 – 19:00
Di & Do	7:00 – 12:00

0421 – 86056

ANSCHRIFT

DIALYSE-ANMELDUNG

Vorname (Pflichtfeld) *

Nachname (Pflichtfeld) *

Straße (Pflichtfeld) *

Hausnummer (Pflichtfeld) *

PLZ (Pflichtfeld) *

Ort (Pflichtfeld) *

Telefon (Pflichtfeld) *

E-Mail (Pflichtfeld) *

Geburtstag (Pflichtfeld) *

Terminwünsche

Wunschtermin *

Wunschtage *

Mo, Mi, Fr tagsüber (6 Uhr/11 Uhr/16 Uhr)

Mo, Mi, Fr Nachtdialyse (21:30 Uhr)

Di, Do, Sa (7 Uhr/12 Uhr)

Weitere Angaben

Waren Sie früher schon einmal bei uns? *

Ja

Nein

Ich werde das Nierenzentrum Bremen Süd vorab telefonisch informieren, wenn ich eine infektiöse Erkrankung wie z.B. Hepatitis, HIV-Infektion oder MRSA habe: *

Ja

Ihre weiteren Infos

Einwilligungserklärung Datenschutz*:

Datenschutz *

Ja, ich habe die Datenschutzerklärung zur Kenntnis genommen und bin damit einverstanden, dass die von mir angegebenen Daten elektronisch erhoben und gespeichert werden. Meine Daten werden dabei nur streng zweckgebunden zur Bearbeitung und Beantwortung meiner Anfrage verwendet. Mit dem Absenden des Kontaktformulars erkläre ich mich mit der Verarbeitung einverstanden.

Vielen Dank für Ihre Nachricht.

Leider ist ein Fehler aufgetreten, versuchen Sie es später bitte nochmal.

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