Joint 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.  

your name: ...
your birthday: ...
your adress: ...
your telefon: ...
your dialysis data:
requested timing of treatment (date / hour):
your   signature:

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