• Registration Form

    Registration Form

    Please fill out to the best of your knowledge
  • Date of Birth:*
     / /
  • Your Gender*

  • Please bring your insurance card with you!

  • I would like the following billing system:*

  • General Health Questions

  • 1. Do you wear glasses?*

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

  • If so, what type of glasses?*
  • Do you want a new prescribtion for glasses?*

  • If you need a new prescription for your glasses, we kindly ask you to make an appointment by phone. We will arrange an appointment on short notice. Tel: 041 711 470 56 or Email: info@augenarztzug.ch

  • 2. Do you wear contact lenses?*

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

  • If so, what type of contact lenses?
  • Do you want new contact lenses?*

  • If you want new contact lenses, we kindly ask you to make an appointment by phone. We will arrange an appointment on short notice. Tel: 041 711 470 56 or Email: info@augenarztzug.ch

  • 3. Are you aware of a Cataract disease?*
  • Have you been treated?*
  • 4. Are you aware of a Glaucom disease?*
  • Have you been treated?*
  • 5. Have you been diagnosed with a Makular Degeneration?*
  • Have you been treated?*
  • 6. Have you had an eye operation?*
  • If so, which eye?*
  • 7. Have you ever had an injury to your eye?*
  • If so, which eye?*
  • 8. Do any of your family members have an eye desease (parents, siblings)?*
  • 9. Have you ever been diagnosed with any of the below mentioned sicknesses?*
  • 10. Do you have allergies?*
  • 11. Are you taking a blood thinner?*
  • 12. Do you take long-term medication?*

  • 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:*
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  • 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: