international patient - admission request form - hôpital Nord Laennec

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 having 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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