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SOLUTION OF PAYMENT AND IMPLEMENTATION RELATIONSHIP IN THE MEDICAL FIELD

 ..::: PAY A CARE :::..     You want to pay for care for a patient, please fill out this form


   1  Personal info   2  Hospital   3  Care Type   4  Conditions   5  Payment   6  Confirmation
 You   The patient
  You are:
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  City:*
  Number & street:*
  Zip code:*
  Name:*
  First Name:*
  Tel. Fixed:*
  Tel. Notebook:*
  Em@il:*
  Kinship:* (With the patient)
  
  The patient is in:
  Country:*
  City:*
  Number & street:
  Zip code:
  Name:*
  First Name:*
  Tel. Fixed:
  Tel. Notebook:
  Em@il:
  No Room Identity:  Age: 
  

          


 
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