Saint Augustin : your private hospital in Tunisia


	MEDICAL IMAGINING DEPARTMENT The clinic is equipped with a technical wherewithal ensuring the : Radiography Scanner Echography Endoscopy

MEDICAL IMAGING DEPARTMENT: TO MAKE AN APPOINTMENT

Please fill in the form below. Mark in the correspondent box 3 chosen dates for your appointment 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 appointment 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 :
An examination to which you wish make an appointment : Is that examination requested by your prescribing doctor : Name of the prescribing doctor :

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.