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Application for holiday dialysis

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Application for holiday dialysis to be submitted by patient

Applicant details

Patient ID

+ country code, where applicable

Contact in case of emergencies

Health insurer details

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.

Current dialysis centre

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