Patient Registration Form

Registration form

- Patient data is stored exclusively with us and processed in accordance with the applicable data protection regulations.

- If a field cannot be filled in, please enter an "x".

Last name *

First name *

Date of birth *

Gender *

1 Last name *

First name *

Occupation *

2 Last name

First name

Occupation

Mother tongue

Street *

No. *

Postal code *

Town/City *

E-mail *

Mobile phone 1 *

Mobile phone 2

Siblings (separate first names with a comma)

Paediatrician *

Town/City *

Health insurance *

Card no.

DI (disability insurance)

Yes No

Case number

I agree that reports may be sent by e-mail to other doctors involved.

I agree that medical data may be transmitted via secure platforms (e.g. HIN).

I agree that invoices may be sent by e-mail.

I agree that simple information (appointments) may be sent by e-mail or SMS (unencrypted).

1. I have read and understood the privacy policy.

2. I know that I can revoke my consent at any time.

3. I acknowledge that data will only be passed on for debt collection with my specific permission.

4. The data will be stored securely for 20 years.

5. I have the right to free information.

Your remarks:

Date

Signature *