Aegean Polyclinics Patient Form EN

CUSTOMER INFORMATION

PATIENT'S INFORMATION

FIST NAME:

LAST NAME:

FATHER'S NAME:

NATIONALITY:

DATE OF BIRTH:

HOME RESIDENCE:

PASSPORT NUMBER:

TELEPHONE:

EMAIL:

RESIDENCE IN GREECE
(Hotel, contract phone):

INSURANCE DETAILS

COMPANY:

TELEPHONE:

EMAIL:

NOTES

I have been informed about the procedures, examinations diagnostic tests, medicines etc that are suitable for the patient’s situation according to current medical best practices, as well as their costs and time frame, and that Aegean Polyclinics is a private establishment adhering to the European Union rules as regards the handling of personal and/or sensitive information.
I have been informed of delays that may occur in the results of molecular covid-19 tests due to delays in the courier companies.

I verify the accuracy of the above information