FORM

Appointment form
- NOT TO BE USED IN AN EMERGENCY -

You may use this form to ask for an appointment. You will receive a confirmation by e-mail with the date and time of the earliest appointment reserved for you. This appointment is binding; should you be unable to attend, please inform us AS SOON AS POSSIBLE. Thank you for your understanding.

	I am already a patient of Dr Haldimann
	I am a new patient

Surname
First name
Date of birth
Street
Town - Postcode
Tel.
E-Mail
Health insurance company
Appointment preferably on:	Monday morning Monday afternoon Tuesday afternoon Wednesday morning Thursday morning Thursday afternoon Friday morning Friday afternoon
Notes: