Questionnaire on
infusions

    Name, First Name *
    Date of Birth *
    Street, No. *
    ZIP Code, City *
    Mobile Number
    How are you insured? *

    You are interested in our infusion therapy. This is a generally well-tolerated and effective treatment option for various complaints. Specific consultation and information will be provided on the day of the first treatment. In advance, we would like to ask you to send us some information about your health status as well as your complaints and wishes.

    Do you currently have or have you had relevant pre-existing conditions in the past? *
    Are you currently using creams, medications or homeopathic remedies? *
    Which symptoms would you like to have treated? *
    Which infusions are you interested in? *
    I CONFIRM THAT ALL THE LISTED DATA IS CORRECT.
    Signature (please sign with your finger or mouse) *

    Are you interested in a treatment?

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