1. REHABILITATION SESSION DETAILS

Duration of stay

Date of the stay ( the date of the stay depends on the availability )

Do You want to have the possibility to extend the stay?

Additional informations

2. INFORMATION ABOUT GUARDIAN / PERSON WHO SUBMITTING

PERSONAL DETAILS OF GUARDIAN / PERSONAL DETAILS OF SUBMITTING PERSON

Name

Surname

CONTACT DETAILS

Phone number

Email

ADRESS

Country

Street

Postal code

City

3. INFORMATION ABOUT PATIENT

PERSONAL DETAILS

Name

Surname

Date of born

Type of disease

Since when?

INFORMATION ABOUT HEALTH

The diagnosis of diseases

IMPORTANT!

I declare, that person who is reported for the rehabilitation don't have impediment to the rehabilitation.

4. SUMMARY

Transport to rehabilitation center:

From WarsawFrom GdańskFrom SzczecinFrom Berlin

How did you hear about us?:

From Official WebsiteFrom discussion forumFrom Google SearchFrom another person