Registration

Patient registration (#16)

Identification
Contact
Treatment
Billing
Time to treatment
Related

Please indicate whether you are the patient or filling in the form on behalf of someone else.

I am the patient

I am filling in on behalf of someone else (e.g. child, relative)

Identification and declaration of the person entitled

Last name of the person entitled

First name of the person entitled

Eligible person's date of birth

Place of birth of the beneficiary

Declaration by the person entitled:

I hereby declare that I have the right to represent the patient.

Patient identification, registration

Patient's surname

Patient's first name

Patient's date of birth

Patient's place of birth

Contact details

E-mail address

Phone number

Personal data relating to the patient's treatment

Patient's sex at birth

Male

Female

Social security number or, in its absence, e.g. passport

What medicine are you allergic to and what reaction have you experienced?

What chronic or infectious disease is it?

What medicines do you take regularly?

Address

Country

Postal code

City

Street, house number

Floor, door

Billing

In whose name can we issue the invoice?

Individual

Company

Health fund

Insurance company

Billing name

Tax number (for company)

Health Insurance Member Identifier

Identifier issued by the insurance company

Please tick if your address and billing address are different.

Billing address

Country

Postal code

City

Street, house number

Floor, door

How much time do you have available for treatment?

Important: if you only have a very short time available (for example, you are leaving the next day), a longer, multi-part treatment is not possible and we will have to opt for a shorter, more urgent treatment. The time available for treatment is key to choosing the right treatment. Please therefore answer thoroughly and accurately.

Please tick the appropriate box for the patient:

Only once I can come (e.g. for a trip)

I am available for a few days, but I can come back several times during this time

For a week or two I am available, so there are several treatments available

For one month or stay longer, I have time for the necessary treatments

I am available for the long term, so we can choose the most optimal treatment

Details of the person to contact in the event of an emergency

Name of person to be notified

Phone number of the person to be notified

Data processing declaration:

From data management information especially the parts on identification, contact, treatment and billing.

Aetna

Alliance

AP Companies

Assist Card

AXA

Bupa

Cigna

CLAL

Class assistance

ECA

Euro Centre

Harel

HTH Wordwide

International SOS

MediHelp

MetLife

MSH International

Savitar Group

TRICARE

United Healthcare

	The condition persists	The condition does not exist
Allergy to medicines
Chronic or infectious disease
Prolonged use of medicines
Pregnant
Breastfeeding

Registration

Identification and declaration of the person entitled

Patient identification, registration

Contact details

Personal data relating to the patient's treatment

Billing

How much time do you have available for treatment?

Details of the person to contact in the event of an emergency

Our services

Sites

Contact

Factsheets