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REHABILITATION OF PATIENTS WITH CEREBRAL PALSY (CP)
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Registration for treatment


Patient
Last name: First name: Date of birth:

Complete address
Street: City: Zip:
Country: Phone: Fax:
E-mail:

Dates of treatment
Arrival:
* Schedule of the treatment sessions is here
Please inform us later about your flight, so we could meet you in the airport

Travel Companions
Full name Date of birth Address*
1.
2.
3.
4.
* Please indicate the address if different from above

Accommodations
Type of the room Number
Single
Double
Triple
Accommodations in the clinic are described here

Comments
Сontact person: e-mail:


 


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