International Office

Registration Form

Fields marked with an * are required

Call *

Description

Name *

Surname *

Date of birth

Mother tongue

Nationality

E-mail *

Phone

Have you been to us ever? *

Yes
No

Diagnosis – What is your diagnosis?

Current complaints – What complaints you have?

Currently used drugs and their dosages

Current and previous course of the disease you have now

Hereditary burden

Your communication for us

How did you know about us?

Sending your data introduced into the feedback form by click on the downstream button, you agree to using your data for reply to your request as well as for communication with you. According to relevant rules of confidentiality, your data will not be communicated to the third part with the exception of cases, when it is justified by relevant Statements on data security, or if we must do it according to the Law. You may withdraw your consent at any moment. In the case of withdrawal all of your data will be deleted immediately. You may be aware of your maintained data at any moment. Please refer to the section “Confidentiality policy” on our web-site for additional information on data security. *