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Cancellation
The cancellation is handled and the official document is filled in according to the cancellation
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* Indicates required question
Email
*
Your email
Type of the service
*
Cancellation of private therapy
Cancellation of group session
Required
Please select the institute where you wish to cancel the pre-booked appointment:
*
Cseppek Háza, Budakalász Centre Institute
Óbudai
Full name of child
*
Your answer
Reason of the cancellation
*
Ilness
Family reason
Other
Other:
Name of therapist
*
Choose
Piroska Bacsó
Sára Balogh
Éva Stofán
Dóra Csillag
Adrienn Fügedi
Ádám Galgóczi
Mária dr. Hollós
Bernadett Kereskényi
Réka Kovács
Emőke Németh
Anikó Pizágné Fehér
Judit Szalai
Boglárka Vidácsné Csiszár
Eleonóra Weiss-Erőss
Andrea Wettstein
Egyéb:
The date of the cancelled appointment:
MM
/
DD
/
YYYY
Time
:
AM
PM
Type of the cancelled early intervention service:
*
Private physiotherapy / Private special education
Private Neuro-hydrotherapy 2. (NHT 2.)
Physiotherapy/special education in Group
Neuro-hydrotherapy 2. (NHT2.) /therapeutic swimming / swimming lesson in Group
Developmental psychology assessment
Psychological consultation/ psychoterapy
Other:
Required
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