Name:

Surname:

Email:

Pathology or illness:

Date of last visit to the doctor:

You were diagnosed with your illness at the hospital:

Do you have a social security card:
YesNo

Do you have a private health insurance card:
NoYes

Age:

Have you used social services:
YesNo

Comment:

I have read and accept the information on donations Information on donations

I have read and accept the information on Personal Data Protection Personal Data Protection

I would like to receive the newsletter with the Foundation's activities