Request of modification or cancellation of appointment

Please notify us by phone or via the form below if you are unable to keep your appointment so that the time slot can be allocated to another patient.

It is also possible to ask for an appointment online via this specific page.

Please fill in all fields marked with an asterisk *.

Last name *
First name *
Birthdate (dd/mm/yyyy) *
Telephone (preferably GSM) *

Current appointment is scheduled on at h in *

Name of the doctor / consultant

Your request * :
Change of date
Cancellation

Comments :