DATE OF REQUEST *

NAME *

BIRTH DATE *

ADRESS *

POSTCODE *

CITY *

COUNTRY

E-MAIL *

PHONE *

FATHER *

MOTHER *

INSURANCE NAME *

In case of hospital stay, if the insurance you have taken out stipulates that your hospital costs will be covered ain paid on presentation of a medical report, please indicate your choice below :

I, the undersigned * authorize the Narbonne Hospital to send a medical report directly to the Doctor of the Insurance Company * ? YesNo

I, the undersigned * undertake to send this medical as soon as possible to the Doctor of the Insurance Company * ? YesNo