Contact

Patient's Information


* Required fields

Title

Academic title

First name*

Last name*

Gender*

Date of birth*

Profession

Country*

Phone (int.prefix)

E-Mail*

Contact Person (different from patient?)*

Health insurance*

Cost assumption by third party?*

Do you require visa assistance?*

Bank account data (in case of refund):

Credit institute

IBAN

BIC


Medical Information

Disease / Disorders/ Symptoms *

Further relevant diagnoses (i.e. heart diseases, cancer, circulation problems, diabetes)

Operations in the past (which kind of and date)

Drugtherapy in the past

Ongoing drugtherapy

Further treatments

Copies of the required medical documents

Which diagnostic tests were performed during the last 3 – 6 months?

 MRI CT / PET-CT Sonography X-Ray Angiography Heart catheter Endoscopy; which kind of?

Preferred specialist (please refer to our website www.atos-clinic.com)

Desired appointment date

Are you interested in a medical follow-up treatment? (Physical Therapy, Post-operative Rehab)

Do(es) you / the patient have any infections at present?

Do(es) you / the patient have any open wounds at present?

Please indicate your / the patient's present mobility status

Additional Information