Registration form Ergotherapy Patient Gender male female Title First name Surname Date of birth Street, no. Postcode Location Telephone number E-mail Legal representative (in the case of people under the age of 18) Health insurance provider Health insurance card no. (Number starts with 807 and consists of 20 digits) Personal identification number/OASI no. Background information regarding registration Background Illness Accident Accident insurance Claim number Data dell’incidente Desired appointment Day Monday Tuesday Wednesday Thursday Friday Time Morning Noon Afternoon Notes regarding desired appointment Prescription Do you have a prescription for ergotherapy? Please note that we can only send you binding appointments appointments when we have a current prescription. Yes No Please send us your valid prescription (no older than 3 weeks from the date of issue) to ergotherapie@kws.ch. Please ask your family doctor or specialist to provide you with a prescription. I have read and agree with the data privacy statement. Leave this field blank