Registration application for the doctors


westmedizin.com • For the doctors

Having filled in the following application for cooperation, you will receive the access to a confidential information of medical profile and to the information we send to the doctors cooperating with us.

REGISTRATION APPLICATION

icon_doc* - Marked fields are mandatory
1. Full Name*:
2. Date and year of birth*:
day/month/year
3. Address and place of residence – country, postal code, town, street, number of house and apartment:
4. Name of the medical establishment, ministry:
5. Phone (with area code)*:

Cellular telephone:

6.E-mail*:
7. Information*:
- Your work status
- Are you planning to send patients in Germany for medical treatment?
- Have you collaborated with our firm before?
- Which is your interest – medical treatment, medical checkup, raising the level of your skill?
- Information required ?
- Special whishes
8. Your message:
Date and place of filling application: