Request form for a vacation stay
   
 
Name
First name
Address
Postal code
City
Country
Telephone
E-mail
Type of dialysis
Habitual dialysis Center
Telephone
Address
Postal code
City
Country
Present specialist
Intended arrival date
Intended departure date
Place of stay
     
    Home | The association | Aix-en-Provence unit | Pertuis unit | Salon-de-Provence centre | Stay in Provence | Registration
     
Copyright © 2016 A.T.M.I.R.