HIRSLANDEN INTERNATIONAL

HIRSLANDEN AG
CORPORATE OFFICE
BOULEVARD LILIENTHAL 2
8152 GLATTPARK
T +41 44 388 75 75

REGISTRATION FORM F +41 44 388 75 80

international@hirslanden.ch

INTERNATIONAL PATIENTS www.hirslanden.com

General information

Name: ____________________________ Gender: ____________________________

First name: ____________________________ Date of birth: ____________________________

Address: ____________________________ Profession: ____________________________

____________________________ Language: ____________________________

____________________________ Nationality: ____________________________

Email: ____________________________ Marital status: ____________________________

Telephone: ____________________________ (attach a copy of passport)

Insurance/direct payer information

 International insurance (incl. insurance details): ____________________________________

 Direct payer (incl. details if different to address): ____________________________________

 Embassy/Ministry of Health (incl. details): ____________________________________

Collection of information from pre-treatment doctors

Have you already been treated in Switzerland? If yes, where?
___________________________________________________________________________________

Name and address of the attending doctor or the clinic in Switzerland or abroad, if applicable:
___________________________________________________________________________________

I hereby agree that Hirslanden may collect the required medical information from the pre-
treatment doctors and any other pre-treatment medical personnel, and I absolve them from their
professional confidentiality within this context.

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I. General information
You are interested in receiving inpatient or outpatient treatment at Hirslanden. The conditions listed below
apply to any requests from international patients for treatments at Hirslanden. We kindly ask that you read
the following information carefully.

Hirslanden International
Hirslanden International is a specialist team of the Hirslanden Private Hospital Group that deals exclu-
sively with international patients. It is your first and direct point of contact for all administrative questions
and will arrange the organisation of your stay in consultation with you and the doctor. The team’s com-
prehensive expertise qualifies it to answer even complex patient questions (annex if required: Additional
services at Hirslanden).

Hirslanden works with affiliated doctors

We would like to draw your attention to the fact that the Hirslanden clinics are doctor-affiliated hospitals.
This means that the clinic provides the infrastructure and nursing services. The medical treatment is pro-
vided by affiliated doctors who are legally and technically self-employed. The affiliated doctor and the
clinic have split liability; i.e. the clinic is liable for its services (accommodation, care and food), and the
affiliated doctor is liable for the medical treatment. The medical care is the subject of a special contract
between the responsible doctor and you as a patient.

II. Costs of your treatment

Quotes and treatment costs
Hirslanden will provide a non-binding quote that includes the estimated cost of the treatment or consulta-
tion based on the information you provide. The costs may vary depending on the course of the treatment
or the actual duration of the hospital stay, and in particular in the event of complications. The final treat-
ment costs are calculated on the basis of the services actually used. Hirslanden will provide a detailed final
invoice on completion of the treatment, which may include a service fee for Hirslanden services.

Deposit and assumption of costs

If you pay for the costs yourself, we will request a deposit on the basis of the cost estimate. This is a
payment on account, which is offset against the actual costs incurred. The deposit must be transferred to
the specified account no later than 10 days before the consultation or treatment. Payment can be made
with current credit or debit cards. If the payment does not arrive in time, Hirslanden reserves the right to
cancel the consultation or the treatment. If the actual costs exceed the deposit payment during the treat-
ment, Hirslanden can request an additional payment on account at any time. Appointment cancellations
or postponements are subject to charges and will be deducted from the deposit (annex if required: Can-
cellation policy).

International insurance
If you are insured by an international insurance company, Hirslanden will use your personal data to clari-
fy cost recovery (cost coverage). However, an assumption of costs cannot be guaranteed. If no assur-
ance of full cost coverage is given before admission to the hospital, a deposit is required. If a payment is
not possible before admission to the hospital, Hirslanden reserves the right to refuse hospitalisation. If
the entire final invoice is not covered by your insurance, you are obliged to bear the uncovered costs
yourself.

Mediation
Hirslanden works with third parties to provide services related to the acquisition and care of international
patients. Hirslanden pays market-based remuneration for these services. At your request, we will gladly
communicate any compensation paid to third parties, if any have occurred in connection with your treat-
ment.

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III. Your health data
Data processing
In order to determine the ideal medical treatment for you and to obtain the cost estimate or extension of
the cost coverage, the doctors and specialists providing medical services, the hospital staff of the
respective Hirslanden clinic and any cost-bearers (insurance) must be able to see and exchange the
information you have provided and the data created by Hirslanden. If you have questions or are
uncertain about the required processing of your health data, please contact international@hirslanden.ch
at any time.

Fee collection
You agree that if your payment is delayed, Hirslanden may forward the information required for the fee
collection to a collection agency in Switzerland or at your place of residence. Naturally, these bodies
would receive only the information and data required for their task.

Significant others/power of attorney

You are free to authorise one or more family members, friends or third parties to take over, in your name
and on your behalf, the correspondence concerning your health data, medical history, deposit, billing etc
related to your treatment at Hirslanden. We will gladly provide you with a power of attorney form. If you
have any questions about power of attorney, please contact international@hirslanden.ch. Power of attor-
ney can be revoked, limited or extended in writing at any time (annex if required: Power of attorney).

With your signature, you agree that all information you have provided is complete and correct,
and that you have understood the information, in particular regarding the data processing neces-
sary for your treatment and the forwarding of your health data.

Swiss law shall be exclusively applicable. The place of jurisdiction is Zurich.

Place, date________________________

_________________________________
Patient signature → attach copy of passport.

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