Registration System

EuroMed - Appointment Registration Form

Please fill out all fields marked with a * ! Thank you.

First Name:*
Last Name:*
Email:*
Telephone:*
Address:
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	Please select doctor and suitable time and date for you.
Doctor:*	--- Medical Dental - dr Szczepan Orthodontist - dr Szywala ---
Date:*	--- Monday Tuesday Wednesday Thursday Friday Saturday
Time:	9am - 12pm 12pm - 3pm 3pm - 6pm
Specified date may be:	Strict Flexible
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Terms and conditions of internet booking*	I agree with terms and conditions.
Statement:	1) We do not provide an automatic booking response. The booking process may take up to four hours. We will do our best to fulfill your request concerning the date and time of the appointment. 2) The confirmation of the appointment will be send to you via SMS or as an alternative via e-mail. 3) Please do not call or text to the number the confirmation message will be sent. If you wish contact us, please use e-mail: info@euromedd.ie or our phoneline: 051 353 920 (dedicated for english speaking patients) or 051 347 060 ( dedicated for polish speaking patients). ******************************************* In order to process your reservation, we collect personal details from you. These details may include (where applicable) your name, addresses, telephone number and e-mail address. In some instances we may also collect information regarding medical conditions. Your data may be used for the following purposes: contacting you in the event of a appointment time change or cancellation, health, administrative, legal purposes, statistical and marketing analysis, systems testing, customer surveys and customer relations communications. We follow strict security procedures in the storage and disclosure of our clients information. Our security procedures require that we request proof of identity before we disclose sensitive information regarding your reservation. *******************************************
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