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Stroke Neuro Rehab Center - Hajdúszoboszló
Application Form 
Please describe your answers in as much detail as possible so that we can tailor your rehabilitation program package to your individual needs! 

By completing and submitting the application form, you accept the data processing information, which can be found at the following link: https://strokerehabilitacio.hu/en/data-protection-statement/ The data you provide will be treated confidentially and will not be passed on to third parties.
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Name *
Date of birth *
MM
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DD
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Phone number *
Email address *
Contact name *
Please describe what neurological injury you have and how long it has been present?
Stroke, Parkinson's disease, multiple sclerosis, accident, etc.  *
Please explain what other health problems you have?  *
Please describe your current condition? (Do you use a wheelchair, cane, walker, do you take care of yourself, what help do you need, etc.) *
What medications do you take and why?
Describe in a few words what daily tasks you can do independently? (Dressing,
cleaning, cooking, walking, climbing stairs, etc.) *
What would you like to improve in? (Lower limbs, movement, upper limbs, etc.) *
Have you ever participated in rehabilitation? When, where and what kind of rehabilitation was it? *
Which of our package offers are you interested in? *
Please indicate the time interval and exact date when you would like to participate in rehabilitation? *
How many days would you like to use?  *
Are you coming with an escort?  *
Would you like us to help you book accommodation and arrange meals?  *
Do you have any food allergies or intolerances?
Are you arriving by car? *
Billing information. Name, zip code, town, street, house number.
 I consent to the processing of my data and accept the  Privacy Statement: https://strokerehabilitacio.hu/en/data-protection-statement/ *
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