Praxis für Viszeral-Chirurgie
Prof. Dr. med. Raoul Droeser
Form
Reason for consultation
Name
First name
Date of birth
Phone
Street, Number
ZIP code
City
E-mail
Health insurance
Insurance Status
Please select
whole Switzerland
Canton of residence
Flex
Semi private
Private
Family doctor model
Yes
No
Priority?
Emergency (same day)
Urgent (Within 2-3 days)
Elective (within 2-3 weeks)
How should we handle you?
Phone
SMS
E-mail
General Practicioner / Other attending physician
Main Complaints
Other diagnoses / surgeries (please attach surgery reports if available)
High Blood Pressure
Yes
No
Diabetes
Yes
No
Heart Diseases
Yes
No
Pulmonary diseases
Yes
No
Kidney Diseases
Yes
No
Existing diagnostics (X-ray, CT, MRI, endoscopies, etc. [please attach reports if available])
Medication
Allergies
Yes
No
Blood Thinners
Yes
No
Smoking
Yes
No
Comments/Request additional reports (e.g., physician‘s reports) (If yes, where?)
Referring physician (name, address, e-mail)
Attach a file (if any)
Website
Submit