Surgery booking order

In accordance with the General Terms and Conditions, I instruct CZ-Wellmed to bindingly reserve a surgery date for me at the clinic named below.

How the surgery booking order works

With this order you instruct CZ-Wellmed to arrange and reserve your surgery date at the chosen clinic. You conclude the treatment contract with the clinic or the doctor. A deposit is required for confirmation; we will tell you the amount and deadlines with the date confirmation (usually within two to three working days). You usually pay the balance directly at the clinic.

Consultation and scheduling with us
Complete and submit the form
Confirmation of date and price, transfer the deposit
Receive your preparation documents

Conditions: T&Cs, withdrawal policy, privacy policy.

Order form as PDF to print (German)

Your contact details

Title

Mr Ms

First name

Last name

Street and house number

Postcode

Town/city

E-mail

Phone / mobile

Date of birth *

* Required fields

Pick-up and return journey (charged) I will send the details in the next few days.

Arrival: transfer from

Airport Railway station

Town/city

Date

Time

Flight no.

Departure: transfer to

Airport Railway station

Town/city

Date

Time

Flight no.

Your surgery details

Please select at least one clinic.

Preferred clinic *Desired surgery *Agreed surgery date / preferred dateNotes

Laboratory / internal medical examination

with my GP at home examination at the clinic

T&Cs and confirmation option

I would like the date and price confirmation by

Post E-mail

I have read and accept the T&Cs, privacy notice and right of withdrawal on this website. As proof we store the time, the version of the texts and a shortened, non-traceable check value of your IP address (see privacy policy).

Option to withdraw

You can submit a declaration of withdrawal online. After sending, you will automatically receive a confirmation of receipt by e-mail.

Withdraw from contract Alternatively by e-mail

If you withdraw by e-mail, a prepared message opens in your e-mail program.

Confirmations and consents *Patient information*
I confirm that I have read and understood the requirements for surgery .T&Cs and privacy policy*
I have read the general terms and conditions and the privacy policy and agree to the T&Cs.Consent to the processing of health data*
I expressly consent to CZ-Wellmed (Natalie Sarah Plitt Services) processing my details that are health data (for example desired procedure, health information, notes) in order to arrange and reserve my surgery date, and passing them on to the clinic I have chosen and its doctors in the Czech Republic or Slovakia (EU) (Art. 6(1)(a), Art. 9(2)(a) GDPR). I can withdraw this consent at any time with effect for the future, for example by e-mail to info@mannop.de.Early start and right of withdrawal*
I expressly request that CZ-Wellmed begins the booking service (firm date reservation) before the withdrawal period has expired. I am aware that I lose my right of withdrawal as soon as the service has been fully performed, i.e. on receipt of my date and price confirmation, and that if I withdraw before then I must pay for the value of the service performed up to that point. Processing usually takes 2 to 3 working days.Note on information*
I acknowledge that the information and advice provided by CZ-Wellmed is of a general nature and is based on experience with the cooperating doctors. It does not replace medical advice and information from the treating doctor.

Please send us photos via the secure photo upload, not by e-mail or WhatsApp.