Admission form

Legal representation (complete only if necessary; must differ from patient’s personal details)

By signing this form, I confirm that I agree to the processing of my data, to access to it by the doctor and to its transmission to third parties in accordance with the patient information on the following page (page 3).
I am aware of the potential risks associated with the exchange of sensitive personal data (possible consultation by unauthorized third parties when using insecure communication tools) and of my rights. I consent to mutual contact between my doctor and myself as a patient, using the contact details given above. The medical practice will transmit patient information exclusively via secure communication channels. I agree that administrative matters, such as rescheduling appointments, may be sent via unencrypted e-mail (from @hin to comme@bluewin.ch, @gmail.com etc.).
The Swiss Federal Health Insurance Act (LAMal) stipulates that patients must receive a copy of the doctor’s bill.

Late payment charges: in the event of late payment and after a minimum of 2 written reminders notices, the file will be forwarded to our external collection agency, which will apply a processing fee payable according to www.payfair.ch.

Appointments that are not cancelled at least 24 hours in advance may be invoiced. Please inform us in good time of any unavailability.