REFERRAL – Neurozentrum Biel-Seeland

HOW TO GET IN TOUCH?

Referral form

^{*=Mandatory fields | Treatments are carried out exclusively on medical referral.}

REFERRAL FORM AS PDF

1. Referring Doctor

2. Patient

3. Assignment

4. Verification / Send

Name doctor / practice* Street / No.* Zip code / City*

Phone* Fax E-Mail*

First name*

Last name*

Birthdate*

Gender*

Street / No.* Zip code / City* Phone Personal* Phone Business Mobile E-Mail Health insurance Insurance number

Medication

Additional documents

Please send us relevant documents (reports, findings, imaging results, etc.) as an upload in the enclosure, separately by e-mail or mail, if the patient does not bring them himself/herself. Thank you...

(max. 5 files, max. 15 MB (total), allowed file types: PDF, JPG, PNG, GIF, BMP)

Upload as an attachmentFollow with separate e-mail on empfang@nzbern.chFollow by mail to Neurozentrum BernAre brought by the patientNo additional documents

URGENT

Assignment to* Reason(s) for assignment* Multiple selection possible, hold down CTRL (strg) and select with a mouse click

Comments

A copy of your assignment, including all your entries, will be sent automatically to your specified e-mail address upon transmission