Centro Medico Teknon - Clinic in Barcelona, Spain

General Information

Specialist Finder

Diagnostic Services

Instituto Cardiovascular Teknon

Instituto Oncológico Teknon

International Visitors Programme

Joint Commission International Accreditation

PATIENT DATA

NAME:*
MOBILE PHONE:.
TELEPHONE NUMBER. (HOME):*
TELEPHONE NUMBER. (WORK):
E-MAIL:

DATE OF BIRTH (dd-mm-yyyy)

* Mandatory fields

DATA ON THE PERSON REQUESTING THE APPOINTMENT

NAME:
MOBILE. TELEPHONE:
TELEPHONE. (HOME):
TELEPHONE. (WORK):
E-MAIL:

INFORMATION ON THE DISEASE:

Have you been seen previously in this centre?

Yes / No

If you are a patient in this centre:

Name of your consultants:

How did you find out about us?

Do you have any health insurance?

Yes / No

Insurance Company:

Your enquiry will be answered within 24 hours (except weekends).

The data requested in this form is essential in order to process your request for an appointment. By filling out and sending this form to Centro Médico Teknon, you accept the automated processing of your personal data and the storage thereof in Centro Médico Teknon's database.

Pursuant to legislation, the applicant will be able to access, rectify or cancel his/her personal data.

Centro Médico Teknon has adopted the appropriate measures to guarantee that your personal data are duly protected. Should you have any doubt, please do not hesitate to contact us by e-mail.

Instituto Oncológico Teknon. C / Vilana, 12. 08022 Barcelona
Telephone: +34 93 290 64 71 Fax: +34 93 290 64 72oncologia@cmteknon.com