Online appointment booking form - Zuger Kantonsspital AG

Onlineanmeldung Sprechstunde EN

Please fill in all fields marked with *. Many thanks.

Body region*

The spine consultation is provided by specialists from the Lucerne Cantonal Hospital. A referral from the family doctor is requested for this.

Medical data

Complaints*

How long have these complaints existed?*

Have you already consulted a doctor because of your symptoms?*

yes

If so, which doctor?

Were radiological images produced (e.g. X-ray, MRI, CT, etc.)?*

yes

If so, when, which and where?

Have you already had surgery because of the symptoms?*

yes

If so, where?

Insurance information

The treatment is based on*

Disease

Accident

Competent health insurance company / insurance*

Data in case of accident

To be filled in only in the event of an accident:

Date of accident

Accident circumstances

Patient data

Salutation*

Date of birth*

Last name*

First name*

Street/no.*

Postcode*

City*

Phone / Mobile*

E-Mail*

The maximum size is 10 MB.

Documents (e.g. medical reports, radiological findings etc. max. 10MB)

Further messages

Attachment 2

Attachment 3

Attachment 4

Attachment 5

General

Do you agree that the Zuger Kantonsspital may obtain the medical information necessary to carry out the treatment from the doctors and medical personnel providing the treatment and release the persons named from the professional confidentiality obligation to this extent?

Obtain medical information*

Yes, I agree that the Zuger Kantonsspital may obtain the medical information necessary to carry out the treatment from the doctors and medical staff providing the treatment and release them from their professional confidentiality obligations.

No, I do not agree that the Zuger Kantonsspital may obtain the medical information necessary to carry out the treatment from the doctors and medical staff providing the preliminary treatment.

Data privacy*

I confirm that I have read the information on data privacy and accept it.