ALZHEIMER HOME

Fill in the application for admission

Interested in placing your loved one in our center? Just fill out an application.

Need a consultation?

Call us.

+420 604 366 496

Prague and Central Bohemia

+420 724 383 772

Moravia

+420 604 366 496

South and West Bohemia

+420 737 810 315

Northeast Bohemia

Request for placement

Form

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Basic data of the candidate

Name*

Surname*

Date of birth*

Health insurance company

Permanent residence of the applicant

Streets*

Descriptive number*

Municipality*

POSTCODE

Place of current residence (if different from permanent residence)

Reason for using the service

Expectations from the service

Contact person

Name*

Surname*

Mobile number

Your e-mail*

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Note

I confirm that I have read the information regarding the processing of personal data of the applicant for admission

Consent to be included in the register of applicants in case I meet the conditions for the use of social services, but at the moment a contract cannot be concluded for capacity reasons or in case of interest in placement in the future.

How did you hear about us?

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