Podologie Riger QUESTIONNAIRE

REGISTRATION FORM

Name

First Name

Last Name

Phone / mobile

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name, Address, Phone

Date of Birth

(day)(month)(year) - no spaces, example: 30081960

AHV Number

Health Insurance

Health Insurance Number

Medical History

(e.g. Diabetes, cardiac problems, kidney disease etc.)

Surgical history

where applicable (e.g. hip surgery, Heart surgery, vascular surgery, etc.)

Smoker

yes

if no: Ex-smoker?

yes

Medication

(prescribed & non-prescribed)

Allergies

What is your foot problem?

I hereby confirm the accuracy and completeness of my information. I also agree that Podologie Riger GmbH may use my personal data given above for medical purposes.

REGISTRATION FORM

LOCATION

OPENING HOURS

CONTACT

STANDORT

ÖFFNUNGSZEITEN

KONTAKT