Saint Augustin : your private hospital in Tunisia


	CHECK-UP Check-up 1 : 330 DT Check-up 2 : 500 DT Check-up 3 : 560 DT Check-up 4 : 690 DT ou 720 DT FRE option : 40 DT See the details of formulas


	For your check-up, do not forget those documents : National Identity Card Medical prescription Social security card (valid) Support documents if you have

CHECK-UP : TO MAKE AN APPOINTMENT

Please fill in the form below. Mark in the correspondent box 3 chosen dates for your check-up with preference order. We will do our best to satisfy your request at our earliest convenience.

The interested service will contact you via e-mail or telephone to confirm your appointments just after form’s reception.

Surname :			First name :
Date of birth :
E-mail address :			Telephone :
Full address :
Preferred check-up day (DD/MM/YY): Date 1 : Hour : Date 2 : Hour : Date 3 : Hour :			Are you affiliated to an insurance ? If yes, the name of your fund : Affiliation number :
Your check-up : Option FRE : Is that examination requested by your prescribing doctor : Name of the prescribing doctor : Some insurances, employers, mutual insurance companies are the object of an agreement with Saint Augustin. Certain examinations such as check-up can be taken care. Is it your case ?

The clinic reserves the right to not answer any incomplete request. Please verify your entered telephone number as well as your e-mail address. All provided information are strictly confidential: you can change it at any time by contacting the clinic via telephone or e-mail.