Borczyk.pl

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Make an appointment. Please enter Your personal data:

Patient’s data
Name
Surname
Address
Phone (Home)
Phone (Work)
Phone (Mobile)
E-mail

Age	Child Teenager Adult

Is it Your first visit in our practice?	Yes No

Type of appointment	Consultation Periodical check-up Oral hygiene – plaque removal Oral hygiene – whitening Toothache Other

The leading doctor (if the patient already had an appointment in our clinic, please enter the doctor’s name)

Patient’s proposal for	The date of the visit The time
I thereby declare that by filling in and sending the above form I agree that my personal data is processed for the marketing needs of Implantology and Esthetic Dentistry Clinic Roman Borczyk, located in Katowice, 5 Czajek Street