Registration Form 

Please fill-In Personal Information:
Name (First, Last) *

* E-mail

Address

Postal (zip) Code

City

* Tel

Fax

* Cellular


Please fill-in information concerning your requirements:
Period of Staying:
14days
21days
28days

Arrival Date:


Number of Guests:
Adults:  + Children: 
Number of Patients: 
Age of patients 


Select below, to which group does the patient belong:
No Pseudomonas
Pseudomonas
Cepacia

Arrangement:

Special request:

   


 



The CF Center

86930 Ein-Bokek Dead Sea, Tel/Fax 972-8-6520256
Main office 16 Shaar-Hagai St, 34554 Haifa, Tel/Fax 972-4-8243102