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+41 91 971 97 94
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Lugano (CH)

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Patient data

First name last name *

Date of birth *

Nation

Address *

Address Line 1

City

State / Province / Region

Phone *

Email

Contact information ( If different from the patient )

first name last name

Date of birth

Country Referent

Address Referent

Address Line 1

City

State / Province / Region

Phone

Email

Reason for contact

Main diagnosis

Specific secondary diagnoses

Benefits required

Welfare benefits basic care
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Specialized nursing services
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Telemedicine service
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Amount of interventions required

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Degree of priority

degree of priority *

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Name of requesting facility *

Contact person of the requesting facility and respective function *

Address *

Patient data

first name last name *

Date of birth *

Country Patient

Address *

Address Line 1

City

State / Province / Region

Phone *

Email

Attending physician *

Insurance company

AVS

Insured Number

Reason for contact

Main diagnosis *

Specific secondary diagnoses

Benefits required *

Welfare benefits basic care
Nursing services
Specialized nursing services
Private benefits
International performance
Telemedicine service
Telecare service

Amount of interventions required

Request for initiation of intake *

Degree of priority

Multiple choice *

Low
Medium
High
Request for in-depth information about the service

Additional text

Requesting Attending Physician

Requesting Attending Physician *

Patient data

first name last name *

Date of birth *

Country Patient

Address *

Address Line 1

City

State / Province / Region

Phone *

Email

Contact person and respective function *

Insurance company

AVS

Insured Number

Reason for contact

Main diagnosis *

Specific secondary diagnoses *

Benefits required *

Welfare benefits basic care
Nursing services
Specialized nursing services
Private benefits
International performance
Telemedicine service
Telecare service

Amount of interventions required *

Request for initiation of intake *

Degree of priority

Multiple choice *

Low
Medium
High
Request for in-depth information about the service

Additional text

Consent Privacy Policy *

Consent to processing of personal data: I declare that I have read the privacy policy and consent to the processing of my personal data for the purpose of providing the requested service. *

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+41 91 971 97 94
info@cad.healthcare

Viale Castagnola 27
6900 Lugano – Switzerland
CHE-178.192.268

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