Online medical questionnaire

Before your first medical consultation, you can pre-register online using our secure form for confidential patient data.

After completing our electronic form of personal data and medical information (see online registration form below), make sure to click on the “save” button at the bottom of the page to automatically send us your completed secure form.

During your first appointment, we will already have your personal data available to be reviewed and signed in the presence of your surgeon.

The confidentiality and security of your personal information is subject to medical confidentiality and we guarantee you an electronic transmission of these forms by a totally secure server.

ONLINE MEDICAL REGISTRATION FORM

Online medical questionnaire

"*" indicates required fields

name*

First name*

Date of birth*

Nationality

Address

Address 2nd line address City Canton Postal code

E-mail*

Business phone number*

Private phone number

Phone number

Marital status

Occupation

Parents/guardian

Health Insurance

AVS number

Employer

Are you receiving social benefits (Social, PC, AI)

You are referred by Doctor (name/city)

Your family doctor (name/city)

Anamnèse – à remplir de manière exacte, ces renseignements étant importants pour vous-même et le médecin

1 Avez-vous été hospitalisé il y a moins de 5 ans ?

Oui

Non

Si Oui, pourquoi :

2 Prenez-vous régulièrement des médicaments (Sintrom, Bisphosphonates, etc…) ou êtes-vous suivi pour une maladie ?

Oui

Non

Si oui, le(s) quel(s)

3 Etes-vous sous-anticoagulants ?

Oui

Non

Si oui, le(s) quel(s)

4 Etes-vous allergique (injections, médicaments, autres allergies : asthme, rhume des foins) ?

Oui

Non

Si oui, le(s) quel(s)

5 Etes-vous enceinte ?

Oui

Non

Problèmes particuliers

Si oui, de combien de mois :

6 Cardio-vasculaires (Troubles du rythme, hyper ou hypotension, autre) ?

Oui

Non

Si oui, le(s) quel(s)

7 Diabète ?

Oui

Non

Si oui, le(s) quel(s)

8 Ulcère d'estomac ou du duodénum ?

Oui

Non

Si oui, le(s) quel(s)

9 Hépatite virale/ HIV/ autre maladie à virus ?

Oui

Non

Si oui, le(s) quel(s)

10 Prothèse de genou/hanche/ autre matériel étranger ?

Oui

Non

Habitudes

Si oui, la(les) quelle(s) :

12 Tabac ?

Oui

Non

si oui, à quelle fréquence :

13 Alcool ?

Oui

Non

si oui, à quelle fréquence :

14 Autres substances/drogues ?

Oui

Non

si oui, à quelle fréquence et la(les)quelle (s) :

I would like to opt for the counting system

Sending the invoice directly from the doctor to my health insurance (Third Party Paying)

Read*

By this document, I authorize the online consultation, based on the insurance card, of the data necessary for billing and its recovery and to transmit them both to the institution issuing the invoice, e.g., in electronic form via the MEDIPORT network, and to the entity responsible for any collection (e.g., collection agency) or to the lawyer (or other third party) handling this matter, as well as to the relevant authorities of the State (e.g., debt enforcement office, court). I irrevocably release Dr. Portier-Marret from medical confidentiality vis-à-vis the aforementioned individuals, authorities, and courts. I also authorize him to recover his invoices by any legal means. Furthermore, I expressly consent herewith to the physician or a person authorized by him making inquiries about my solvency with the necessary data. My physician is entitled to request medical records concerning me for consultation and to communicate medical results to the subsequent treating physician. By my signature, I declare that the above-mentioned information is true and that I am aware that the physician sends his invoices in electronic form via the MediPort network.

I acknowledge and accept that in case of late payment, the following fees will be applied: Processing fees (at the earliest 80 days from the date of invoicing, when transmitted to a collection agency) according to the amount of the debt in CHF: 37 (up to 19); 58 (up to 59); 145 (up to 399); 225 (up to 999); 285 (up to 1999); 385 (up to 2999); 575 (up to 4999); 685 (up to 6999); 825 (up to 9999); 1375 (up to 19999); 2600 (up to 49999); 6% of the debt (from 50000).

Choice of law and venue clause:

-Applicable law: Legal relations between the parties are exclusively governed by Swiss law, especially regarding rights related to the examination, treatment, and all services of Dr. Portier-Marret or his representative in the maxillofacial surgery office in La Riviera, Switzerland.
-Legal venue: The exclusive legal venue for all disputes related to the treatment or the aforementioned relationship with Dr. N. Portier is Lausanne, Switzerland. Dr. Portier-Marret has the right to appeal to other competent courts at the patient’s domicile.

Read and approved*

Sans titre*

I have read and accept the privacy policy

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OOnline medical questionnaire

ONLINE MEDICAL REGISTRATION FORM

Online medical questionnaire

Anamnèse – à remplir de manière exacte, ces renseignements étant importants pour vous-même et le médecin

Problèmes particuliers

Habitudes

D'Do not hesitate to contact us !