Questionnaire
The purpose of this questionnaire is to obtain basic information for the preparation and organization of your medical stay.
Information on the medical treatment sought
Provide any relevant diagnostic information, including medical reports and recommendations from your treating physician
Check if you will need a preliminary medical consultation
Declarations and authorizations
Data Privacy
By signing this form, you acknowledge that your personal and medical information will be used only for the purpose of organizing your medical stay, in accordance with current data protection legislation.
I authorize the processing of my personal and medical data as part of the organization of my medical stay*
Medical consent
I acknowledge that I have provided accurate and complete information and I understand that this information is necessary to ensure the best quality of service in organizing my medical stay.
I confirm that all information provided in this form is accurate.*
Signature
