Application form for medical treatment

This post is also available in: Deutsch (German)

Praxis Lemm | Bötzowstraße 10 | 10407 Berlin - Prenzlauer Berg | Telephone: 030 45306785

We would like you to complete the patient form (click here to download) as preparation and bring it to the initial meeting.

This questionnaire is based on the main aspects of integral medicine to permit a diagnosis in its entirety.

Please fill out the fields marked with a *

first name*:

family name*:

telephone*:

Street / no.

Postcode / Town

e-mail*:

Date of birth*:

New patient*:

Appointment for*:

Desired date*:

Urgency of your problem*:

Preferred date*:

(Please enter a date and time or "flexible".)
I'm informed of the costs and accept these.
Type of insurance

Type of insurance*:

Name of Health Insurance*:

Comment:

I agree to the processing and the forwarding of the information I entered above. I can withdraw my consent at any time with immediate effect.

Office hours
Mon, Wed: 2 p.m.- 8 p.m.
Tue, Thur, Fri: 9 a.m.- 5 p.m.

Availability
On site
by telephone 030 45306785
or by online appointment

publishing information:
address:
Praxis Lemm
Bötzowstraße 10
10407 Berlin - Prenzlauer Berg

telephone:
030 45306785telefax:
030 45306786

website:
http://www.allergie-weg-berlin.de/

e-mail:
info@berliner-akupunkturpraxis.de

official firm:
Praxis Lemm

responsible:
Dr. med. Vesna Lemm / Owner / Family doctor, internal medicine, holistic medicine,acupuncture and midwife

bank details:
IBAN: DE63 3006 0601 0207 0269 00
BIC: DAAEDEDDXXX

title:
Medical Doctor

Licensed by the Medical Association of Berlin
www.aerztekammer-berlin.de

title:
Midwife

Supervisory authority:
Landesamt für Gesundheit und Soziales Berlin

Licensed by Bundesrepublik Deutschland in Mettman (NRW)

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