Registration Form ENG

Registration Form

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

DayMonthYear
FemaleMaleDo not want to specify
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:
Send the medical bill directly to my health insurance company (Tiers payant)Send the medical bill directly to me (Tiers garant)
General Health Questions
YesNo
If you wear glasses, please bring them along with you to your appointment
Farsighted GlassesNearsighted GlassesVarifocal GlassesI do not know
YesNo
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
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.
Hard lensesSoft lensesI am not sure
YesNo
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
YesNo
YesNo
If so, who diagnosed it and when?
YesNo
YesNo
If so, who diagnosed it and when? Which eye-drops were you given?
YesNo
YesNo
If so, who diagnosed it and when? Which medication were you given?
YesNo
Right eyeLeft eye
When and where did the operation take place?
YesNo
Right eyeLeft eye
When did it happen and where did you get treatment?
YesNoI do not know
If so, who and which desease?
NODiabetes Type IDiabetes Type IIHIVThyroid diseaseHepatitis/liver diseaseMultiple sclerosisThrombosisCardiac arrhythmiaHeart attackHead-aches/MigranesHigh blood-pressureStrokeCancerOther
What kind of cancer?
YesNo
If so, which ones:
YesNo
If so, which one:
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 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

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 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