Formular




© Dr.H.G.Schulz - Version 1.0 vom 05.08.2011

... Contact ...

Dear Madam or Sir,

Thank you very much for your interest.

Using this contact form you can communicate with us and ask questions (German or English only). We kindly request that you truly and completely provide all the information required so that we can process your inquiry as quickly as possible. This saves us time (i.e. for further emailing needed because the requested information was not completely provided) which we need in order to care about our patients.

The information you provide will be emailed to

Dr. Henning G. Schulz (Chief of staff, visceral surgery)

and will be dealt with as soon as possible. We thank you for your understanding and look forward to receive your email request.

Formular

Angaben zur Person:

Last name :

First name :

Date of Birth :

Sex:

Size (in centimeter (e.g.: 174)):

Weight (in Kilogram):

Address:

Street:

ZIP-Code:

City:

Country (e.g. Germany, Austria, etc):

Kontakt:

e-mail:

Please note the correct spelling of your E-Mail-Adress !!!!

Phone-Number (private):
Phone-Number (at work):
Mobile Number:

(Please enter your Phone-/Mobile-Number with international prefix (e.g. +49 for Germany or +39 for Italy)

Health insurance :

gesetzlich

gesetzlich + privat zusatzversichert

privat

What are your questions ?

Before you fill out this field, we recommend an outline of the history of your disease (e.g. symptoms in the beginning of the disease, development of symptoms, previous therapy).

Remarks :

Thank you for your questions !