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international patient - admission request form - hôtel-Dieu

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 an 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:

 

Health care needs


Pathology/health problem:
 
Soins demandés:
 
Healthcare needs:

Information that may help establish your treatment plan:

 


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