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On-line form
Patient’s information
Name:
Surname:
Phone no.:
E-mail address:
Attending physician:
lek. stom. Michał Donatt
lek. stom. Olga Lonska-Donatt
lek. stom. Magda Kortas
lek. stom. Adam Krüger
będzie to moja pierwsza wizyta w Klinice
Type of visit
Follow up visit
Toothache
Hygiene of oral cavity
other
other:
Preferred date / hour of the visit
Day / month / year:
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2009
2010
Hour:
By filling and sending this form I hereby agree for the processing of my personal data by MMG Sp. z o.o. with the seat in Pruszcz Gdański.