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About you

Please start with capital letters. 2 to 25 characters (letters, spaces, hyphens, apostrophes only).
Please start with capital letters. 2 to 25 characters (letters, spaces, hyphens, apostrophes only).
Is the date correct?
Please start with capital letters. 2 to 25 characters (letters, spaces, hyphens, apostrophes only).

Contact details

Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Only 4 to 5 digit numbers please.
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Please only numbers, hyphens, spaces and +.
Is the e-mail correct? (Format: xx@xx.xx)
I wish...
Reports by e-mail:
Emails encrypted:
Appointment confirmations:

This person may receive all necessary data in an emergency

Is the date correct?
Please start with capital letters. 2 to 25 characters (letters, spaces, hyphens, apostrophes only).
Please start with capital letters. 2 to 25 characters (letters, spaces, hyphens, apostrophes only).
Please only numbers, hyphens, spaces and +.
Is the e-mail correct? (Format: xx@xx.xx)
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Only 4 to 5 digit numbers please.
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).

Your insurances

Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Note: Some insurance companies use the AHV or policy number as the insured person number.
Supplementary hospital insurance
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).

Doctors and medical contacts

To keep the form clear, we only use the masculine form here.
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).
Only 2 to 40 characters please (letters, spaces, hyphens, inverted commas, full stops).

Are you currently taking medication?

Examples:
Myocin 10mg 0 0 1 0
Neoprofen 50ml 1 1 0 0

Do you have allergies?

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