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Patient form
You can fill up the patient form in
PDF file
or online.
OASI-Nr.:
Patient ID:
First Name
*
Last Name
*
Date of Birth
*
Profession
Street
*
Post code
*
City
*
Canton
*
Telephone
*
Mobilephone
*
Email
*
Civil status
Complementary Insurance (ICA) /Section
Reason for referral
Brief diagnosis / Findings
Anamnese:
*
Remarks
Name of your referrer
Name and address of your physician
Date
Message
submit
