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Anmeldung

Kursanmeldung


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Online Anmeldung
Generated with MOOJ Proforms Version 1.3
* Diese Felder werden mindestens benötigt um Ihre Angaben verarbeiten zu können.

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Anmeldung zur Schulung im Schulungszentrum Diabetes Wittlich e.V.


Jede/r zu schulende Patient/-in muss in ein DMP der Krankenkassen eingeschrieben sein, da die Schulungskosten ansonsten in voller Höhe privat in Rechnung gestellt werden.

DMP-Nr. bitte eintragen:
Bitte Auswählen: *
Kundendaten
Krankenkasse: *
Nachname: *
Vorname: *
Geburtsdatum: *
PLZ / Wohnort: *
Strasse und Hausnummer: *
Telefonnummer: *
Mobil:
E-Mail-Adresse:
Auswahl
Schulungswunsch: *
--> Typ – 1 Diabetes
--> Typ – 1 Diabetes mit Insulinpumpe (CSII)
--> Schwangerschaftsdiabetes
--> Typ – 2 Diabetes ohne Insulintherapie
--> Typ – 2 Diabetes mit CT
--> Typ – 2 Diabetes mit ICT
--> Kombinationsschulung Diabetes und Hypertonie
--> Hypertonie
--> COPD
--> Asthma
--> Blutgerinnung, SPOG
--> Ernährungsberatung
Bemerkungen:
Datenschutzerklärung gelesen und akzeptiert *
- JA - gelesen / akzeptiert

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