Application holiday dialysis

Personal data

First & last name patient

Home address

Phone number

Date of birth

First and last name contact person

Language

Dialysis center

Name dialysis center

Address dialysis center

Phone number dialysis center

Treating physician

Email treating physician

Current dialysis regimen

Holiday information

Holiday address

Phone number

Holiday dialysis regimen

Holiday dialysis from

Holiday dialysis to

Contact in case of problems

Health insurance data

Name + number health insurance

Name insurance holder

Registration number + code

Transport

We kindly ask that you assume responsibility to arrange the transportation to and from our center. A list of the recognized transportation companies can be obtained from our social service at + 32 50 45 97 96 or ewout.laureyns@azsintjan.be. An attestation of transport can be provided to you at the and of your stay with us.

Application holiday dialysis

Campus Sint-Jan

Campus SFX

U bent hier

Application holiday dialysis

Campus Sint-Jan

Campus SFX