Appointment cancellation Form

Welcome to appointment cancellation page. If you want to cancel your appointment, please fill in the personal details and necessary information below. * These fields are necessary to fill in.

Name and surname *

E-mail

Date of Birth

Appointment Date *

Doctor /specialization *

Additional Information *
Patient Card
Corporate clients
Individual clients

Clinic's address *

CM W-wa Postępu
CM W-wa Racławicka
CM W-wa Chmielna
CM W-wa Migdałowa
CM W-wa Puławska
CM W-wa Szernera
CM W-wa Al. Stanów Zjednoczonych
CM W-wa Jerozolimskie
CM W-wa Ken
CM Gdańsk Al. Zwycięstwa
CM Gdańsk Al. Jana Pawła
CM Gdynia
CM Łódz
CM Poznań Roosevelta
CM Poznań Wichrowa
CM Wrocław Legnicka
CM Wrocław Wołowska
CM Kraków Wadowicka
CM Kraków Mehoffera
CM Katowice
CM Bydgoszcz
CM Olsztyn

Please contact me to arrange a new appointment

Yes
No

Contact telephone No:

Additional comments:

By accepting this form you hereby agree to the processing of your personal data for the marketing purposes of LUX MED, in accordance with the Personal Data Protection Act (Journal of Laws No 133, item 883).

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Appointment cancellation

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