Reservation Company Reservation for * Surgery Thalasso-therapy Full name * Date of birth * Country * Address * Phone * Email * Number of accompagnant * Type of act chosen * Associated pathology Diabetes? * Yes No If yes, insuline? Yes No Hypertension Yes No Heart disease? Yes No If yes, which? Allergies? Oui Non If yes, which? Tumoral disease? Yes No If yes, which? Other health problems? If you have had surgery before, list them.