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Buchinger

Reservation form

Dear patient:

This information is necessary for us to be able to determine whether your stay in our clinic would be appropriate in your case.
Title
   
Surname (*) First name (*)
   
Street (*) Number (*)
   
Postal Code (*) Town (*) Country (*)
     
Telephone (*) Fax Email (*)
   
Profession Languages spoken
   
Date of birth (*) Place of birth
(Minimum age for admission in the clinic is 15 years.)
   
Type and category of accommodation required? (*) Superior Single Double
  Comfort Single Double
  Standard Single Double
       
Day of arrival (*) Day of departure (*)
   
Have you ever stayed at Buchinger Marbella before? Yes No
Have you ever stayed at Buchinger Bodensee (Germany)? Yes No
Did you follow the fasting therapy when you were there?          Yes No
   
What are your reasons for undertaking a fasting therapy? A chronic illness A severe illness
  Prevention General recuperation
  Relaxation Weight loss
  Break the Smoking habit Other reasons
     
Are you presently under medical care? (*) Yes No Why?
(If you are undergoing treatment please bring all medical reports)
   
Are you taking medication? (*) Yes No Which?
     
     
Do you drink alcohol? (*) Yes No Frequently Occasionally
   
Do you take any other kind of toxins? (*) Yes No Which?
     
How frequently? Regularly Sometimes
   
Do you have any intolerance to any particular foodstuffs? (*) Yes No Which?
Do you have any intolerance to any medications? (*) Yes No Which?
     
Are you handicapped or in need of special care? (*) Yes No
If yes, please specify    
     
Weight (kg) Height (cm)

(The initial medical examination will determine the type of treatment to be undertaken. In case of doubt please contact our Medical Department)
Who has recommended our clinic to you?
A Doctor:
Please give name:
Clinic Address:
Patient:
Please give name:
Family:
Please give name:
Friend:
Please give name:
Media:
Which one?:
Other:
Which one?:

Do you need any additional information?
Yes No Please give details
   
Should we provide for any particular requisites before or during your stay?
Yes No Please give details

Suggestions
I have read and accept General Conditions and Clinic Regulations.
I accept Data Protection Directive.

(*) Mandatory fields
In compliance with article 5 of Law 15/1999, regulating the right to information governing the storage of data, we advise you as to the following: Data of a personal nature, that may appear on this form, shall be incorporated into a file called “Gestión de Reservas y Admisión” (Bookings and Admissions Management), created by Resolution of the Spanish Data Protection Agency.

The purpose of the file is the management of bookings and admissions at Clínica Buchinger S.A. Data are to be used for processing the bookings and admissions of individuals who request the services of Clínica Buchinger S.A. Data concerning the physical persons who act as deponents herein, shall only be used in accordance with the previously established terms.

You shall have the right to access your personal data, amend them or, when applicable, cancel them by addressing CLINICA BUCHINGER S.A. Avda Buchinger s/n C.P. 29602 Marbella.
 
Buchinger Marbella
Clinic for Therapeutic Fasting
and Integrative Medicine

Avda. Buchinger s/n
E-29602 Marbella
Tel. (+34) 952 76 43 00
Fax (+34) 952 76 43 05
Reservation (+34) 952 76 43 01
clinica@buchinger.es