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Practice of Specialists in Dialysis Dr. med. Claudia Braun & Dr. med. Karsten Schröder Reinhardtstr. 39, 10117 Berlin, Germany Please - print the blank fax sheet, write and fax +49 / 30 / 280 62 57. |
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| your name: | ... |
| your birthday: | ... |
| your adress: | ... |
| your telefon: | ... |
| your dialysis data: | |
| requested timing of treatment (date / hour): | |
| your signature: | |
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