Appointment

If you wish to cancel an appointment with one of our paediatricians or paediatric specialists, please fill out this form indicating the date of the appointment.

If you need to request a new appointment, please leave your information and we will schedule it.

Sending this form entails acceptance of our Privacy Policy.

CHILD’S FULL NAME(*)

E-mail (*)

SUBJECT

SPECIALIST

SPECIALISATION

DATE CANCELLED

WOULD YOU LIKE US TO GET IN TOUCH WITH YOU TO SCHEDULE A NEW APPOINTMENT?

 Yes No

DO YOU PREFER BEING CONTACTED BY EMAIL OR TELEPHONE?

 E-mail Telephone number

CONTACT TELEPHONE(S) (*):

NOTES

I have read and accept the Data Protection clause

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