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Appointment type *

First name *

Last name *

Phone *

Email *

Health insurance company *

Attachment (FT prescription) * Before submitting, please check that the FT prescription has been filled in correctly here.

Medical documentation (medical report and other relevant documents)

Date of birth *

Attachments (medical report related to your condition, if available)

Note (please briefly describe the difficulties you are coming in for) * Note (please tell us your foot size, or the shoe size the insoles will be selected for. For children, please also add the foot length in cm) *

How we handle the data from this form is described in our personal data processing information.

Appointments: https://www.rehali.cz/objednat-se/ or email us.

PHYSICAL THERAPY FOR DIRECT PAYMENT - the easiest way to get a therapy appointment.

Do you have any other questions? Or email us.