OP registration

OP registration

Personal details

First name*

Surname*

Gender

male

female

Date of birth*

Street / No.

City / Postcode

Tel Business

Private phone

Mobile phone*

E-mail*

AHV No.*

Health insurance / Accident insurance*

VEKA-Nr.*

80756

Health insurance*

In the event of an accident:

Date of accident

Claim number

Invoice to

Practice

patient

Details of the operator

Name of surgeon*

First name*

E-Mail*

Name of the medical practice or clinic*

Details of the operation

Diagnosis*

ICD Code (german terms only)*

Secondary diagnoses

Operation*

Side*

OP Date and time*

Duration of the operation*

Further information on the procedure

Positioning

Anaesthesia*

Notes on storage

Notes on anaesthesia

final information

Special requests

Anaesthesia consultation

Anaesthesia consultation required

Sobriety

No fasting required

I accept the privacy policy .*

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