Richiesta di prenotazione

Reservation request

Use this form to send us your booking request; we will contact you as soon as possible to arrange your appointment.

Fields marked with * are mandatory.

Patient data

First name *

Last name *

Birthday *

Place of birth *

Fiscal code *

Gender *

Male
Female

Address

Residence address *

City of residence *

Postal Code *

Contatti

Phone number *

E-mail address *

What do you want to book?

Area *

Service

Infiltrazione Ecoguidata Acido Ialuronico A Basso Peso Molecolare

80 €

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Privacy

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