Registration for referring physicians
Patient's personal details
Title
*
Patient's first name
*
Patient's last name
*
Street, No.
*
ZIP code
*
Place of residence
*
Phone
*
Mobile
(optional)
Email
*
Date of birth
*
Address + telephone number of the referring authority
*
Email of the referring authority
*
Health insurance
(optional)
Insurance number
(optional)
Insurance
*
Social history
(optional)
Consumption behavior/other addictive substances
(optional)
Diagnosis
*
Medication
*
Data protection
Previous treatments
(optional)
Upload file
*
Previous treatments
(optional)
Is there a guardianship?
(optional)
If yes, please provide complete details of the guardianship.
(optional)
I agree to the
Privacy policy
I agree.
*
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