Do you wish an appointment at our clinic? Send your request online! You will receive a.s.a.p. a confirmation from us.


Please provide us your personal data here:
First and last name:*
E-mail address:
Street address:*
City:*
Phone:
Fax (required if asking for a fax confirmation):

) Required fields*
Please select one or more of the following services for your next appointment:

Fertility advice	Cancer prevention check-up
Teenager consultation	Mammography
IUD implant	Cancer aftertreatment check-up
Anti-aging therapy	Hormonal substitution halfyear check-up
Pregnancy regular check-up	Check-up 6-8 weeks after delivery
Check-up after surgery	Acupuncture
Contraceptive administration halfyear check-up	Mammasonography

Please select the day and time the most convenient for your appointment:
	Mornings Afternoons Mornings or Afternoons

Please write here your particular issues and concerns you want to discuss during this appointment (if any):


Please select the type of confirmation you wish to receive:
E-mail Phone Fax
Thank you !

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