Application for holiday dialysis to be submitted by patient

Applicant details

Patient ID

Surname

Firt name

Gender

Date of birth

Address

E-mail

Nationality

Identity card No.

Telephone/mobile number

+ country code, where applicable

Preferred language of communication

Contact in case of emergencies

Contact telephone/mobile number

Health insurer details

Policy holder name

Policy number

EHIC or approval slip issued by health insurer

Submit a digital copy of your European Health Insurance Card (EHIC) or approval slip issued by health insurer here. Bestanden moeten kleiner zijn dan 2 MB. Toegestane bestandstypen: gif jpg jpeg png pdf doc docx.

Insurer

Health insurer address

Health insurer telephone number

Health insurer fax number

Health insurer e-mail address

Current dialysis centre

Dialysis centre name

Dialysis centre address

Dialysis centre telephone number

Dialysis centre fax number

Dialysis centre e-mail address

Treating doctor

Current dialysis schedule

Desired holiday dialysis reservation period: from

Desired holiday dialysis reservation period: until

Haemodialysis shift

Last dialysis session before holiday

First dialysis session after holiday

Holiday address details

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