Online assignment form

Assign your patient online here. You will then receive a confirmation email with all the details you entered in the form.

If the relevant information is not already included in the uploaded documents, please fill in all fields. Thank you for your assignment!

Your name(required)

First name Last name

E-mail address(required)

Telephone

Address

Street & No. City Region ZIP CODE Country

Files

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Accepted file types: pdf, png, jpg, Max. File size: 256 MB.

Medical question

Additional information (only to be completed if not shown in the annex)

Patient details:in

Yes

Salutation

Mr.

Woman

None

Name

First name Last name

Date of birth

Telephone

E-mail address

Address

Street & No. City Region ZIP CODE Country

Health insurance

Supplementary insurance

The HerzGefässZentrum Im Park is one of the most comprehensive networks of cardiovascular experts in Switzerland