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Patient Registration Form

If you have already arranged an appointment and would like to send us your details electronically, please complete the form below and return it to us.

If you would like to book a consultation with us but do not yet have an appointment, please ask for a referral from your General Practitioner or from the doctor treating you, or you can contact our Team Secretary direct.

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Patient no. (where applicable)
Consultation / Admission date
Team
(e.g. foot, knee, rheumatology etc.)
Surname (as on identity card/passport)*
First name*
Gender*
Date of birth*
Né(e)
Nationality
Home town
Tax domicile (town/city)
AHV no.
Religion
Address*
Postcode, place of residence*
Telephone no *
Telephone no
Telephone no
Email
Profession
Employer
Employer’s postcode/town
Person to be notified in an emergency: surname, first name and address (for minors, details of parents)
Degree of kinship
Surname
First name
Address
Telephone no
Telephone no
Telephone no
Referring doctor to the Balgrist University Hospital
Surname
First name
Address
Patient’s GP
Surname
First name
Address
Reason for treatment*
Date of the accident
Sickness fund basic insurance
Additional insurance
Membership no.
Accident insurance
Claim no.
Military insurance
Claim no.
Disability insurance/IV office
Case number
Insurance category*
Private payer
Do you have a heart pacemaker or an ICD (defibrillator)?*
* I hereby certify that the information given is correct.
  * Must be filled in  
   
     

Highlights

Patient registration:

online registration now possible.

Consultation Orthopedics

Patients Information

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Where to find us?

Universitätsklinik Balgrist
Forchstrasse 340
8008 Zürich
Tel.: 044 386 11 11
Fax: 044 386 11 09

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Contact

Universitätsklinik Balgrist
Forchstrasse 340
8008 Zürich

Phone 044 386 11 11
E-Mail

Information

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Disclaimer

© 2014 Balgrist University Hospital

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