Patient registration Patient registration form Welcome to our medical office! We ask you to fill out this online registration form immediately (the link sent to you is valid for a maximum of 1 hour after you click on it). in order to reduce the mutual contact times in our practice to what is medically necessary. You agree that we store your data in accordance with the generally applicable data protection regulations. Your registration will be forwarded in encrypted form to our HIN-Secure-Mail orthopaedie-glaeser@hin.ch. The fully completed registration form (front and back) will then be printed out in our practice and must be signed by you at the start of your appointment. Please bring your health insurance card with you to your appointment. Our goal is to provide an accurate diagnosis of your symptoms and a completely individualized treatment plan tailored to you. For this reason, we ask you to answer all of the following questions about your personal details, previous illnesses and complaints/pain as accurately as possible (by ticking them off, adding and/or underlining if you answered "yes"). Thank you very much for your kind assistance. Name* Mrs.Mr.Dr.Prof. Salutation First name Last name Date of Birth* Address* Street City ZIP Phone / Mobile Number* E-Mail* Health insurance company* Your health insurance card number starting with 807 ....* General practitioner model?* Yes No Referring or primary care physician (Name, Adress, EMail)* Medically necessary dataBody height / cm* Body weight / kg* For women. Are you pregnant? Yes No What motivates you to come to me and which expectations do you have?*Are your current symptoms caused by an accident?* Yes No If yes, state date and course of the accident as well as accident insurance, accident insurance number and claim numberWhich pre-existing conditions and surgeries are you aware of?*Special diseases concerning your family members (parents, grandparents, siblings)?*Metabolic disorders (including diabetes=sugar, lactose, gluten, histamine intolerances)?*Allergies, intolerances (e.g. patches, medications, etc.)?* Yes No What kind of allergies/intolerances?Do/did you suffer from infectious diseases such as hepatitis/jaundice, HIV/AIDS?*Consumption of alcohol, nicotine, drugs? If yes, what kind of and how much?*Are you taking any medications, e.g., for diabetes, cardiovascular, blood thinning (e.g., Marcumar, ASS=Aspirin, Xarelto, Plavix), psychotropic drugs? If yes, how is the dosage?*Did you or your family members experience any incidents related to pain management or local anesthesia?* Yes No Did you have any hypersensitivity reactions (e.g., circulatory disorders, itching) occurred during previous examinations with X-ray contrast media?* Yes No Are there any recent findings (lab, imaging) and/or reports?* Yes No If yes, please be sure to take them along to our appointment!!!With my signature I confirm the correctness of the personal and medical information given on both pages of this registration form. At the same time, I will provide Dr. Gläser and his team with all reports and findings from doctors and hospitals that are required for the clarification and treatment of my current complaints or illness. I consent to the invoice being sent directly online to the health insurance company via the Ärztekasse Genossenschaft, Agentur Zürich Schaffhauserstrasse 470, 8052 Zürich after my insurance card has been scanned. (Otherwise, please inform us directly). Cancellations for follow-up appointment(s) must be made in good time, i.e. 24 hours in advance by telephone or email, in order to be able to reallocate the appointment(s) to other patients. I also declare my agreement that Dr. Gläser, depending on my symptoms, may carry out therapy measures which, on the one hand, may lead to an initial worsening with an increase in my complaints and, on the other hand, may reduce my ability to react, e.g. when driving a motor vehicle or riding a bicycle in road traffic (e.g. in terms of an increased risk of accidents). I am also aware that my physical and mental performance may be impaired afterwards, so that immediate rest and recuperation are absolutely necessary for me. All activities that require increased concentration, coordination and endurance for their execution (see above) are to be avoided by me after such therapy measures. In case of non-observance or contravention, I myself assume responsibility for any consequential damages of such impairments.