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Please enable JavaScript in your browser to complete this form.Type of contact required: *Contact PatientsContact Hospitals/ClinicsContact Primary Care Physicians Patient data First name last name *Date of birth *NationNationAfghanistanAlbaniaAlgeriaAndorraAngolaEelAntarcticaAntigua and BarbudaSaudi ArabiaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBelarusBurmaBolivia (plurinational state of)Bonaire, Saint Eustatius and SabaBosnia-HerzegovinaBotswanaBrazilBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeChadChileChinaCyprusColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaIvory CoastCroatiaCubaCuraçaoDenmarkDominicaEcuadorEgyptEl SalvadorUnited Arab EmiratesEritreaEstoniaEthiopiaRussian FederationFijiPhilippinesFinlandFranceGabonGambiaGeorgiaSouth Georgia and the South Sandwich IslandsGermanyGhanaJamaicaJapanGibraltarDjiboutiJordanGreeceGrenadaGreenlandGuadeloupeGuamGuatemalaGuernseyFrench GuianaGuineaEquatorial GuineaGuinea-BissauGuyanaHaitiHondurasHong KongIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)IcelandBouvet IslandIsle of ManChristmas IslandIsland of Saint BarthélemyAland IslandsCayman IslandsCocos Islands (Keeling)Cook IslandsFalkland Islands (Malvinas)Faroe IslandsHeard and McDonald IslandsNorthern Mariana IslandsMarshall IslandsNorfolk IslandsSaint Pierre and Miquelon IslandsSolomon IslandsSvalbard and Jan Mayen IslandsTurks and Caicos IslandsVirgin Islands (U.S.)Virgin Islands (British)Minor outer islands of the United States of AmericaIsraelItalyKazakhstanKenyaKyrgyzstanKiribatiKorea (People's Democratic Republic of)Korea (Republic of)KosovoKuwaitLesothoLatviaLebanonLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth Macedonia (Republic of)MadagascarJerseyMalawiMaldivesMalaysiaMaliMaltaMoroccoMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Confederation of States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNiueNorwayNew CaledoniaNew ZealandOmanNetherlandsPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPitcairnPolandFrench PolynesiaPuerto RicoPortugalQatarUnited Kingdom of Great Britain and Northern IrelandArab Republic of SyriaCzech RepublicCentral African RepublicLao People's Democratic RepublicDominican RepublicReunion (Island of)RomaniaRwandaWestern SaharaSaint Kitts and NevisSaint Vincent and the GrenadinesSaint-Martin (French Part)SamoaAmerican SamoaSan MarinoSt. Helena, Ascension and Tristan da CunhaSaint LuciaSao Tome and PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (part of the Netherlands)SlovakiaSloveniaSomaliaSpainSri LankaUnited States of AmericaVatican City StateSouth AfricaSudanSouth SudanSurinameSwedenSwitzerlandTajikistanTaiwan, Republic of ChinaTanzania (United Republic of)French Southern TerritoriesBritish territory in the Indian OceanThailandEast TimorTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUkraineUgandaHungaryUruguayUzbekistanVanuatuVenezuela (Bollivian Republic of)VietnamWallis and FutunaYemenZambiaZimbabweeSwatini (Kingdom of)Address *Address Line 1CityState / Province / RegionPhone *Email Contact information ( If different from the patient ) first name last nameDate of birthCountry ReferentNationAfghanistanAlbaniaAlgeriaAndorraAngolaEelAntarcticaAntigua and BarbudaSaudi ArabiaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBelarusBurmaBolivia (plurinational state of)Bonaire, Saint Eustatius and SabaBosnia-HerzegovinaBotswanaBrazilBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeChadChileChinaCyprusColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaIvory CoastCroatiaCubaCuraçaoDenmarkDominicaEcuadorEgyptEl SalvadorUnited Arab EmiratesEritreaEstoniaEthiopiaRussian FederationFijiPhilippinesFinlandFranceGabonGambiaGeorgiaSouth Georgia and the South Sandwich IslandsGermanyGhanaJamaicaJapanGibraltarDjiboutiJordanGreeceGrenadaGreenlandGuadeloupeGuamGuatemalaGuernseyFrench GuianaGuineaEquatorial GuineaGuinea-BissauGuyanaHaitiHondurasHong KongIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)IcelandBouvet IslandIsle of ManChristmas IslandIsland of Saint BarthélemyAland IslandsCayman IslandsCocos Islands (Keeling)Cook IslandsFalkland Islands (Malvinas)Faroe IslandsHeard and McDonald IslandsNorthern Mariana IslandsMarshall IslandsNorfolk IslandsSaint Pierre and Miquelon IslandsSolomon IslandsSvalbard and Jan Mayen IslandsTurks and Caicos IslandsVirgin Islands (U.S.)Virgin Islands (British)Minor outer islands of the United States of AmericaIsraelItalyKazakhstanKenyaKyrgyzstanKiribatiKorea (People's Democratic Republic of)Korea (Republic of)KosovoKuwaitLesothoLatviaLebanonLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth Macedonia (Republic of)MadagascarJerseyMalawiMaldivesMalaysiaMaliMaltaMoroccoMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Confederation of States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNiueNorwayNew CaledoniaNew ZealandOmanNetherlandsPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPitcairnPolandFrench PolynesiaPuerto RicoPortugalQatarUnited Kingdom of Great Britain and Northern IrelandArab Republic of SyriaCzech RepublicCentral African RepublicLao People's Democratic RepublicDominican RepublicReunion (Island of)RomaniaRwandaWestern SaharaSaint Kitts and NevisSaint Vincent and the GrenadinesSaint-Martin (French Part)SamoaAmerican SamoaSan MarinoSt. Helena, Ascension and Tristan da CunhaSaint LuciaSao Tome and PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (part of the Netherlands)SlovakiaSloveniaSomaliaSpainSri LankaUnited States of AmericaVatican City StateSouth AfricaSudanSouth SudanSurinameSwedenSwitzerlandTajikistanTaiwan, Republic of ChinaTanzania (United Republic of)French Southern TerritoriesBritish territory in the Indian OceanThailandEast TimorTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUkraineUgandaHungaryUruguayUzbekistanVanuatuVenezuela (Bollivian Republic of)VietnamWallis and FutunaYemenZambiaZimbabweeSwatini (Kingdom of)Address ReferentAddress Line 1CityState / Province / RegionPhoneEmail Reason for contact Main diagnosisSpecific secondary diagnoses Benefits requiredWelfare benefits basic careNursing servicesSpecialized nursing servicesPrivate benefitsInternational performanceTelemedicine serviceTelecare serviceAmount of interventions requiredRequest for initiation of intake Degree of priority degree of priority *LowMediumHighRequest for in-depth information about the serviceAdditional text - priority grade Fill in the following fields: Name of requesting facility *Contact person of the requesting facility and respective function *Address * Patient data first name last name *Date of birth *Country PatientNationAfghanistanAlbaniaAlgeriaAndorraAngolaEelAntarcticaAntigua and BarbudaSaudi ArabiaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBelarusBurmaBolivia (plurinational state of)Bonaire, Saint Eustatius and SabaBosnia-HerzegovinaBotswanaBrazilBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeChadChileChinaCyprusColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaIvory CoastCroatiaCubaCuraçaoDenmarkDominicaEcuadorEgyptEl SalvadorUnited Arab EmiratesEritreaEstoniaEthiopiaRussian FederationFijiPhilippinesFinlandFranceGabonGambiaGeorgiaSouth Georgia and the South Sandwich IslandsGermanyGhanaJamaicaJapanGibraltarDjiboutiJordanGreeceGrenadaGreenlandGuadeloupeGuamGuatemalaGuernseyFrench GuianaGuineaEquatorial GuineaGuinea-BissauGuyanaHaitiHondurasHong KongIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)IcelandBouvet IslandIsle of ManChristmas IslandIsland of Saint BarthélemyAland IslandsCayman IslandsCocos Islands (Keeling)Cook IslandsFalkland Islands (Malvinas)Faroe IslandsHeard and McDonald IslandsNorthern Mariana IslandsMarshall IslandsNorfolk IslandsSaint Pierre and Miquelon IslandsSolomon IslandsSvalbard and Jan Mayen IslandsTurks and Caicos IslandsVirgin Islands (U.S.)Virgin Islands (British)Minor outer islands of the United States of AmericaIsraelItalyKazakhstanKenyaKyrgyzstanKiribatiKorea (People's Democratic Republic of)Korea (Republic of)KosovoKuwaitLesothoLatviaLebanonLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth Macedonia (Republic of)MadagascarJerseyMalawiMaldivesMalaysiaMaliMaltaMoroccoMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Confederation of States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNiueNorwayNew CaledoniaNew ZealandOmanNetherlandsPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPitcairnPolandFrench PolynesiaPuerto RicoPortugalQatarUnited Kingdom of Great Britain and Northern IrelandArab Republic of SyriaCzech RepublicCentral African RepublicLao People's Democratic RepublicDominican RepublicReunion (Island of)RomaniaRwandaWestern SaharaSaint Kitts and NevisSaint Vincent and the GrenadinesSaint-Martin (French Part)SamoaAmerican SamoaSan MarinoSt. Helena, Ascension and Tristan da CunhaSaint LuciaSao Tome and PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (part of the Netherlands)SlovakiaSloveniaSomaliaSpainSri LankaUnited States of AmericaVatican City StateSouth AfricaSudanSouth SudanSurinameSwedenSwitzerlandTajikistanTaiwan, Republic of ChinaTanzania (United Republic of)French Southern TerritoriesBritish territory in the Indian OceanThailandEast TimorTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUkraineUgandaHungaryUruguayUzbekistanVanuatuVenezuela (Bollivian Republic of)VietnamWallis and FutunaYemenZambiaZimbabweeSwatini (Kingdom of)Address *Address Line 1CityState / Province / RegionPhone *EmailAttending physician *Insurance companyAVSInsured Number Reason for contact Main diagnosis *Specific secondary diagnoses Benefits required *Welfare benefits basic careNursing servicesSpecialized nursing servicesPrivate benefitsInternational performanceTelemedicine serviceTelecare serviceAmount of interventions requiredRequest for initiation of intake * Degree of priority Multiple choice *LowMediumHighRequest for in-depth information about the serviceAdditional text Requesting Attending Physician Requesting Attending Physician * Patient data first name last name *Date of birth *Country PatientNationAfghanistanAlbaniaAlgeriaAndorraAngolaEelAntarcticaAntigua and BarbudaSaudi ArabiaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBermudaBhutanBelarusBurmaBolivia (plurinational state of)Bonaire, Saint Eustatius and SabaBosnia-HerzegovinaBotswanaBrazilBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeChadChileChinaCyprusColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaIvory CoastCroatiaCubaCuraçaoDenmarkDominicaEcuadorEgyptEl SalvadorUnited Arab EmiratesEritreaEstoniaEthiopiaRussian FederationFijiPhilippinesFinlandFranceGabonGambiaGeorgiaSouth Georgia and the South Sandwich IslandsGermanyGhanaJamaicaJapanGibraltarDjiboutiJordanGreeceGrenadaGreenlandGuadeloupeGuamGuatemalaGuernseyFrench GuianaGuineaEquatorial GuineaGuinea-BissauGuyanaHaitiHondurasHong KongIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)IcelandBouvet IslandIsle of ManChristmas IslandIsland of Saint BarthélemyAland IslandsCayman IslandsCocos Islands (Keeling)Cook IslandsFalkland Islands (Malvinas)Faroe IslandsHeard and McDonald IslandsNorthern Mariana IslandsMarshall IslandsNorfolk IslandsSaint Pierre and Miquelon IslandsSolomon IslandsSvalbard and Jan Mayen IslandsTurks and Caicos IslandsVirgin Islands (U.S.)Virgin Islands (British)Minor outer islands of the United States of AmericaIsraelItalyKazakhstanKenyaKyrgyzstanKiribatiKorea (People's Democratic Republic of)Korea (Republic of)KosovoKuwaitLesothoLatviaLebanonLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth Macedonia (Republic of)MadagascarJerseyMalawiMaldivesMalaysiaMaliMaltaMoroccoMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Confederation of States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNiueNorwayNew CaledoniaNew ZealandOmanNetherlandsPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPitcairnPolandFrench PolynesiaPuerto RicoPortugalQatarUnited Kingdom of Great Britain and Northern IrelandArab Republic of SyriaCzech RepublicCentral African RepublicLao People's Democratic RepublicDominican RepublicReunion (Island of)RomaniaRwandaWestern SaharaSaint Kitts and NevisSaint Vincent and the GrenadinesSaint-Martin (French Part)SamoaAmerican SamoaSan MarinoSt. Helena, Ascension and Tristan da CunhaSaint LuciaSao Tome and PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (part of the Netherlands)SlovakiaSloveniaSomaliaSpainSri LankaUnited States of AmericaVatican City StateSouth AfricaSudanSouth SudanSurinameSwedenSwitzerlandTajikistanTaiwan, Republic of ChinaTanzania (United Republic of)French Southern TerritoriesBritish territory in the Indian OceanThailandEast TimorTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUkraineUgandaHungaryUruguayUzbekistanVanuatuVenezuela (Bollivian Republic of)VietnamWallis and FutunaYemenZambiaZimbabweeSwatini (Kingdom of)Address *Address Line 1CityState / Province / RegionPhone *EmailContact person and respective function *Insurance companyAVSInsured Number Reason for contact Main diagnosis *Specific secondary diagnoses *Benefits required *Welfare benefits basic careNursing servicesSpecialized nursing servicesPrivate benefitsInternational performanceTelemedicine serviceTelecare serviceAmount of interventions required *Request for initiation of intake * Degree of priority Multiple choice *LowMediumHighRequest for in-depth information about the serviceAdditional textConsent 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. *View privacy policyCommentSEND