Appointment arrangement Magnetic Resonance Imaging (MRI) about contact form Please, fill all fields. (* is duty field) Address Please choose. Mrs. Mr. Your surname * Your given name * Date of birth (DD.MM.YYYY) * Insurance * E-mail contact * Phone contact * When you are the best by telephone to reach (For example: 14:00 o'clock) * Your doctor * Others Magnetic Resonance Imaging (MRI) Body part / organ Please select Abdominal cavity / pelvis Angiographie Elbows Finger Foot Soft tissues of the neck Main Wrist Hip Knee Bones Brain Kidney Prostate gland Shoulder Ankle joint Thorax Spinal column, Cervical vertebra column Spinal column, Dorsal vertebra column Spinal column, Lumbar vertebra column Other examination Consent I realise that a data transmission by e-mail offers to no 100% of protection. My given data, in special my phone number / mail address, may be used for the establishment of contact to agree on an appointment. Besides, I have been pointed out to the fact that the elevation, processing and use of my data on voluntary base occurs. Blocked mails are extinguished after successful appointment assignment or on cancellation from the system. My cancellation explanation becomes I arrange: Radiologische Praxis Trier Fleischstraße 12-13 54290 TRIER or kontakt@roentgenpraxis-trier.de