To set an appointment at XO Dental Clinic please call our Reception or complete the following appointment form and send back to us. We will contact you immediately after receiving the form.

* - Obligatory fields

Name and surname*


Postcode und City*

Phone number*

Phone number
Private Company Mobile
E-mail address

Patient's age*
Child Teenager Adult
First visit

Type of the visit

Suggested date of the visit*

Suggested time of the visit

If you enter all the data you accept that they will be processed for the purpose of the customer service of NZOZ XO Dental Clinic in accordance with the Data Protection Act of August 29, 1997 (Journal of Laws of the Republic of Poland No. 133, item 883).