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075-351-9200

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Request An Appointment for Travel Dialysis

Thank you for accessing our website.

Please make sure to fill in all the fields marked [Required] in the form below and click the “Confirm input” button.

Patient name
Required
Date of birth
Required
Sex
Required
Languages you can communicate in (multiple choices possible)
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Mobile phone number
Required
Email address
Required
Email address (confirm)
Required
Please enter the same email address as above.
The dialysis facility where you are receiving dialysis treatment
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Required
The telephone number of the dialysis facility where you are receiving dialysis treatment
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Have you ever visited our clinic before?
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Required
Desired date
Required

*If you would like to choose a date that is not available, please enter the desired date and time in the “Consultation details” section.

Desired time
Required
Desired time

*If you would like to consult multiple times, please enter the desired date and time for the second session onwards in the "Consultation details" section.

Dialysis time
Required
How did you find out about our facility?
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Please enter your consultation details
*If you would like to use the service for multiple days, please write your desired dates and times here.
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