Registration form for the check-up (Essential & Professional)

Dear patient,

To take part in your check-up at the European Prevention Center (EPC), we need a little more information to plan your appointment. Please complete the following form in full. If you would like a Check-Up Professional, please also indicate the relevant examinations on the last page.
We look forward to hearing from you. If you have any questions, please do not hesitate to contact us.

Date of the checkup

Salutation

Title

First name

Surname

Address of the participant

Date of birth

E-Mail (Business)

E-Mail (Private)

Phone (Mobile - Private)

I agree to be informed by e-mail / SMS / letter about the possibility of re-booking an appointment / re-presentation.

I agree to receive information by e-mail / SMS / letter about news from the EPC on the topics of cardiac and preventive medicine

I do not wish to receive e-mails / SMS / letters

My family doctor

Other practitioners (name, address, function)

I would like to take advantage of the following additional points (only for Professional Check-Up):

Message

I confirm that I have read the Privacy policy and have taken note of them.

Signature

Here you will find information on the daily schedule: