Ce formulaire de test envoie déjà les notifiations. "*" indicates required fields Contact formDo you have a question? Do you have a request? Need an appointment? Fill in the form below to make your request. First name*Last name*Do you have a Luxembourgish identification?* Yes No Identification number*Date of birth*Email address* Phone number*Contact reason*Choose here the contact reasonRequest an appointmentPrescription renewal / certificat requestCancelling an appointmentProblem with a billDoctor concerned*Choose your doctorDr BorsiDr GratiaDr SimonDr NardaiDr MartinDr OlivierI don't have a regular doctorType of appointment*Choose your appointment typeGynecological controlPregnancy / normal follow upEmergencyPost PartumScar control, after surgeryPost operation controleInsertion / changing IUD/Spiral/ImplantSurgical 2nd opinionEsthetic medicine - InjectionsEsthetic surgery of the breastOtherLast control date* Day Month Year Date of last period* Day Month Year Emergency type*Choose your appointment typeGynecologicalPregnancyYour problem*Choose your appointment typePainInfectionAbnormal bleedingBreast pain, lumpProblems with breastfeedingOtherDate of delivery* Day Month Year Date of operation* Day Month Year Expected date of menstruation* Day Month Year Are you pregnant?* Yes No Please specify*Planned date* Day Month Year Would you like us to propose a new date?* Yes No What do you need ?* Prescription Certificate Please note the name of the medication*Why and when?*Additional informationAttachment(s) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 5. PhoneThis field is for validation purposes and should be left unchanged.
