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

Card number

Health insurance*

Invoice to*

Practice

patient

Details of the operator

Name of surgeon*

First name*

Place*

Details of the operation

Diagnosis*

Secondary diagnoses

Operation*

Side*

OP Date and time*

Duration of the operation*

Further information on the procedure

Storage

Anaesthesia*

Notes on storage

Notes on anaesthesia

Special requests

Anaesthesia consultation

Anaesthesia consultation required

Sobriety

No fasting required

I accept the privacy policy .*

final information

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