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>>Appointment request : 1st step (identity)

AppointmentsThis form allows you to ask for an appointment online. We will contact you by phone or GSM, or by Email, to definitely fix the desired appointment.

You will find useful contact data via the electronic list of consultations and consultants.

It is also possible to cancel or re-arrange online an existing appointment.

Please fill in all fields marked with an asterisk *.

Is this appointment request  for your child or for another person  ? *

Information about the patient :

Name of the family doctor/pediatrician *

Has this request been recommended by your doctor ? Yes  No

Has the patient already been treated at QFCUH ? *  Yes  No

Gender * : Male  Female

Last name *
First name *
Birthdate (dd/mm/yyyy) *
National number (on the SIS-card)

Street *   Nr *   Mailbox
City *     Post code *
Country *

Identity of the person submitting the request :

Last name of the asking person *
First name of the asking person *

E-mail *
E-mail (checking) *

Preferred contact method (so that we can reach reach you during office hours) :

Telephone * : >>Telephone * (checking) :
GSM * : >>GSM * (checking) :

! In case of urgent request, thank you for favouring direct contact (by phone or on the spot).
In case of life-threatening emergency, call the following number : 112.