Novinari Novog lista 24 sata sa nama

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.

Novinari Novog lista 24 sata sa nama

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