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Demographics Form

    Female Partner Data




    Date of Birth *







    Male Partner Data (if exists)




    Date of Birth




    Contact Data








    By whom were you referred to the Assisting Nature Unit?

    Without further authorization, my personal data and result of the treatments can be used in scientific research, while protecting the personal identification from the data. Enclosed information is strictly confidential. Assisting Nature follows certain patients’ information policies in order to protect sensitive information, as it is strictly required by Greek and European Union applicable Laws and directives.

    Espa