Application form example

FORM EXAMPLE FOR COURSE RESERVATION

APPLICATION FORM

To the chief medical officer
of GU «Respublikanskaia Bolnitsa Speleolechenia»
Mr. Levchenko P.A.

Patient`s Full Name: ___________________________________

Patient`s Age:  _______________________________

Patient`s Full address:_________________________

________________________________________

________________________________________

________________________________________

Home phone:______________________

Mobile phone:_____________________

E-mail ________________________



* Please accept me (my child) for speleotherapeutic course from DD/MM/YYYY to DD/MM/YYYY ,

Patient`s diagnosis: ______________________________________________________

Extracts from the patient's medical records attached:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

I have read and agree with all terms of treatment and accommodation.

I will cover all costs and charges associated with my(my child) accomodation  and treatment at the hospital.

________________________________________

(date) (signature, full name)





English (United Kingdom)Russian (CIS)

General Management:

Chief medical officer – Levchenko Pavel Alexandrovich.

Deputy chief physician – Dubovik Natalia Nikolaevna.











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