Special Doctors GmbH Friedrichstraße 58 10117 Berlin
Tel: +49 30 2260 53000 Fax: +49 30 2260 53001 praxis-berlin@special-doctors.com

Anamnesis questionnaire

Please take your time to fill out the questionnaire. If you have any questions, please ask us!





    How did you become aware of us? Please quote

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    Known diseases, please quote:

    Diabeteshigh blood pressurerheumatismHIVGastro-intestinal diseasethyroid diseaseHepatitis





    Are we allowed to send you a message as an notification to an appointment?

    YesNo

    Are we allowed to send any documents to yiu and your doctor in charge?

    YesNo

    Fee agreement

    Dear patient, we call attention to the fact that the contractual relationship is between the patient and the treating physician. Your insurance contract doesn’t affect the contractual relationship anyway. Depending on your insurance contract you might only get reduced reimbursement of costs. You would then have to offset the difference

    Datum

    Signature

    Your data is only used for the treatment and our administration. By submitting the form you accept our Disclaimer.
    Mit der Nutzung dieses Formulars erklären Sie sich mit der Speicherung und Verarbeitung Ihrer Daten durch diese Website einverstanden.