Registration Form ENG

Registration Form

Please fill out to the best of your knowledge
First Name*
Last Name*
Date of Birth:*

DayMonthYear
Your Gender*

MaleFemaleN/A
Address:*

Street Address

Street Address Line 2

City:

Zip Code:
Phone/Mobile:*
E-Mail:*
Employer
Employer Tel Number:
Health insurance:
Please bring your insurance card with you!
Referring doctor:
Your general practitioner:
I would like the following billing system:*

Send the medical bill directly to my health insurance company (Tiers payant)Send the medical bill directly to me (Tiers garant)
General Health Questions
1. Do you wear glasses?*

YesNo
If so, what type of glasses?*

Farsighted GlassesNearsighted GlassesVarifocal GlassesI do not know
Do you want a new prescribtion for glasses?*

YesNo
If you wear glasses, please bring them along with you to your appointment
2. Do you wear contact lenses?*

YesNo
If so, what type of lenses?*

Hard lensesSoft lensesI am not sure
Do you want new contact lenses?*

YesNo
If you wear contact lenses, please remove them 24 hours before your appointment. This allows the doctor to conduct a more accurate eye examination.
3. Are you aware of a Cataract disease?*

YesNo
Have you been treated?*

YesNo
If so, who diagnosed it and when?
4. Are you aware of a Glaucom disease?*

YesNo
Have you been treated?*

YesNo
If so, who diagnosed it and when? Which eye-drops were you given?
5. Have you been diagnosed with a Makular Degeneration?*

YesNo
Have you been treated?*

YesNo
If so, who diagnosed it and when? Which medication were you given?
6. Have you had an eye operation?*

YesNo
If so, which eye?*

Right eyeLeft eye
When and where did the operation take place?
7. Have you ever had an injury to your eye?*

YesNo
If so, which eye?*

Right eyeLeft eye
When did it happen and where did you get treatment?
8. Do any of your family members have an eye desease (parents, siblings)?*

YesNoI do not know
If so, who and which desease?
9. Have you ever been diagnosed with any of the below mentioned sicknesses?*

NODiabetes Type IDiabetes Type IIHIVThyroid diseaseHepatitis/liver diseaseMultiple sclerosisThrombosisCardiac arrhythmiaHeart attackHead-aches/MigranesHigh blood-pressureStrokeCancerOther
What kind of cancer?
10. Do you have allergies?*

YesNo
If so, which ones:
11. Are you taking a blood thinner?*

YesNo
If so, which one:
12. Do you take long-term medication?*

YesNo
If so, which ones:
13. Do you have any further questions that we can address together?
By submitting this form, I understand and confirm:

1. All the information provided is accurate and complete to the best of my knowledge.

2. My doctor is authorized to request medical records about me for Inspection and to send medical results to the doctor providing follow-up treatment.

3. The submission of this form serves as a digital signature, acknowledging the truthfulness of the details shared.
Place/date:*

MonthDayYear
Date
The HEAL Augenpraxis complies with all swiss data protection regulations, which came into force on September 1, 2023 (Act: 321 StGB).

Swiss Data Protection Policy
Should be Empty:

Registration Form

Please bring your insurance card with you!

General Health Questions

If you wear glasses, please bring them along with you to your appointment

If you wear contact lenses, please remove them 24 hours before your appointment. This allows the doctor to conduct a more accurate eye examination.