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Centre for Pain Medicine
Contact/Referral
Physician Refferal Form

Physician Refferal Form

Information from the Reffering Physician
First name *
Last name *
Street and number *
ZIP code and town *

Personal details:
Gender

Female Male

First name *
Last name *
Date of birth * (DD/MM/YYYY)
Street and number *
ZIP code and town
Telephone No. Home *
Telephone Office
Mobile
E-Mail
Nationality
Mother language *

Reason for pain problem:
Reason for pain problem

Illness
Congenital
Accident

Date of accident (DD/MM/YYYY)
Brief description of reason for pain problem *

Who will cover the cost of this examination?:
Health/Accident Insurance: Insurance *
ID number of insured person *
Insurance coverage

General, canton of residence
General, countrywide
Private insurance
Semi private

Supplementary insurance: Insurance
ID number of insured person
IV: IV branch and city
Case number
AHV number

Please solve the following (for spam protection):
The number 9 plus the number 5 =

* Fields must be completed

On receiving this contact form, the Centre for Pain Medecine will send you a more detailed questionnarie regarding quor pain problem.

Additional information

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Members of the Benefactors' Association receive CHF 200,000 if they suffer spinal paralysis as a result of an accident. Become a member

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