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Patient's name and surname*

Patient's Date of birth*

Patient's Address*

Postal Code, City*

Social Security No.*

Health Insurance Card Valid Until*

Contact phone or mobile*

Contact email (optional)

Patient comes from:*

Health Institution

Home

Foster Care

Nursing Home

Other (specify)

Diagnoses Relevant for Treatment*

Is the patient infectious or at risk of infections?*

Yes

No

If you or the persons who accompany you have limitations in mobility (walking with an aid, requiring a wheelchair for movement) or performance of daily routines (hygiene, dressing, nutrition), please indicate*

Yes, there are restrictions on mobility or performing daily routines

No, fully self-contained and mobile

Does the patient have secured accommodation after discharge?*

Yes

No

I would like to acquire services based on:**

Based on a referral: A valid referral from the primary care physician with the indicated health service attached with the medical documentation

Without a referral (payment only): Scheduling an appointment with the attached medical documentation according to the valid prices of the CHIF increased by 50% in accordance with the Decision of the Insula County Hospital, or in accordance with the ICH service packages and the price lists of services outside the contract with the CHIF

Optional:

I have read, understood and comply with the policy relating to my personal data. Personal data entails all information collected and stored in a form that allows you to be personally identified, either directly (e.g. by name) or indirectly (e.g. by telephone number) as a natural person. Before you provide us with this information, we recommend that you read this document that outlines our guidelines for protecting customer privacy.

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