international patient - admission request form - hôpital Bellier


Identification of the patient



Title:

First (given) name:

Last (family) name:

Nationality:

Date of birth:

If the patient is a minor, identification of the legal guardian:


First (given) name:

Last (family) name:

Nationality:

Date of birth:

Relationship with the patient:

Contact information (patient or patient's legal guardian if minor):


Street number and name:

Further adress information:

City:

Postal code:

Province/State:

Country:

Telephone:

Email:

Financial information


The medical and hospitalization charges will be paid by:

Name:

International bank account number (Iban):


The patient has or will apply for funding for treatment in a member country of the EU under the S2 route:




 
The patient has received authorization for funding for treatment in a member country of the EU under the S2 route:




If the patient is resident of a country ha-ving a signed bilateral social security agreement with France:

Agreement reference:

Healthcare needs


Pathology/health problem:

Healthcare needs:

Medical speciality:

Information that may help establish your treatment plan:


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