Application form guest dialysis - location Texel

Please send us the form no later than 6 weeks before the start of the first holiday dialysis week.

To avoid disappointment, we advise you to wait to book your holiday accommodation until your dialysis request has been approved by us.

Application form guest dialysis

Location *

Sex *

Initials *

Name *

Street *

House number *

Postal Code *

City *

Country *

Phonenumber *

Mobile number

Email address *

Date of birth *

Name/Address/Tel. no. of your own dialysis centre *

Weeknumber(s) in which you wish to have dialysis *

Frequency *

Preferred days *

If applicable your insurance number

Family practice

Have you ever had dialysis at one of our locations? *

Extra comments