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?

    YesNo

    DO YOU PREFER BEING CONTACTED BY EMAIL OR TELEPHONE?

    E-mailTelephone number

    CONTACT TELEPHONE(S) (*):

    NOTES

    I have read and accept the Data Protection clause


    contacte

    Ens trobaràs a:

    contacte