OPAN® • The platform for online patient registrations

Information about the assignment

Earliest possible first use on site
Sunday, May 31, 2026 between 10 and 12 pm

Desired first use

After consultation with the customer

As soon as possible

Specific date and time of day

Date

Time

Location of operation

Street

Street number

c/o address

Postal code

City

Care needs, care assignment and further care instructions
Care needs

Care assignment

Living/Housing situation

Reason for application
Main diagnosis / Reason for application

Secondary diagnosis / information relevant for care

Additional medical information

Family doctor informed
The family doctor is aware of this registration

Medication and material
Current medication

Medication and material supply

No medication or material is required

Required medication or material is organized independently by the patient or relatives

A prescription and medication / supplies for 1-2 days are given to the patient.

Other

Medication and material details

Documents
Attachment
Patient data / customer data

First name

Last name

Gender

Date of birth

AHV number

Home address
Different residential address?
Yes, the patient's/client's residential address is not at the location of operation

Street

Street number

Address suffix

Postal code

City

Country

Additional data
Civil status

Religious denomination

Spoken languages

Nationality

Patient has no phone (select only in exceptional cases)

E-mail of the patient / customer

Insurances

Event

Accident date

Accident number

Relatives / Reference person

Supervising / responsible physicians
Who fills in this application?

Sender

Other
Not listed in directory

Name

Responsible person for the application
Salutation

First name

Last name

Email

Email during absence

Contact center for inquiries

Contact person for inquiries

Reachability
Reachability

Preferred method of contact

Responsible person asks to be contacted

Contact patient / client directly

Direct contact with relatives or a designated contact person

Preferred contact option for queries by telephone

Preferred contact option for queries by email

Additional information

I hereby confirm
Patient / customer informed
The patient / customer is informed about the registration and agrees

Privacy Policy
I agree with the terms of use and the privacy policy

Security & Privacy

Cancel

Who fills in this application?
Application
Confirmation

Referrer

Provider

Login

Register

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Language selection

OPAN® • The platform for online patient registrations

Spitex • Application • A-DA339OFM