Bakon - Patient Questionnaire

First Name Birth Registration Number ^ This is not correct number, try "I am a foreigner" option. Insurance Company VZPVoZPČPZPOZPZPŠZPMVRBP

Last Name Date of Birth Nationality CZSK

Academic Degree Ident. number I am a foreigner

Address − Street
E-mail
Postcode

House Number
City
Telephone Number

Alternative Contact Person

Telephone Number

PLEASE NOTE THAT IF YOU CANCEL YOUR APPOINTMENT WITH LESS THAN 48 HOURS’ NOTICE, WE ARE ENTITLED TO CHARGE A MISSED APPOINTMENT FEE IN ACCORDANCE WITH THE CURRENT PRICE LIST.

Information and Settings

Medical Information

Please check and specify if you suffer from any of the medical conditions listed below, for how long and since when:

NoYes

Number of weeks

Declaration

I confirm that I have read the conditions of treatment and warranties and the price list of treatments and accept them. The information given in this form is true and I have understood everything.

Date

Signature Delete

^ Please sign the form again.

Your personal data will be processed in accordance with Regulation (EU) 2016/679 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data – the General Data Protection Regulation (GDPR)

Patient Questionnaire

General Information

Information and Settings

Medical Information

Declaration