› Dialyse Centrum Groningen

Holiday request

Gender*
Name*
Date of birth
Adress
ZIP code and city
E-mail*
Phone number
Mobile phone number
I would like to dialyze in (choose a city)
Kies hier uw gewenste vakantielocatie*
Preferred starting date
Preferred last holiday dialysis date
Preferred dialyzes days*
- Monday - Wednesday - Friday
- Tueasday - Thursday - Saturday
- No preferrence
Preferred part of the day*
- Morning
- Afternoon
- No preferrence
Yes, I have taken note of the privacy statement of Dialyse Centrum Groningen.*
You can find out privacy statement here
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I would like to dialyze in (choose a city)