Admission Form

I would like to be admitted to the Parkinson’s Disease Clinic Ortenau.

Patient details

Mandatory field Name*
Mandatory field Surname*
Mandatory field Date of birth*
Mandatory field Street/ No.**
Mandatory field Postal code /City*
Mandatory field Telephone*
Mandatory field E-mail*
Mandatory field Nationality*
Mandatory field Address of your general physician*
Mandatory field Address of your neurologist*
Mandatory field Person responsible for payment/ health insurance*
Text box	Your Message
Mandatory field Spam protection*	What is the sum of 6 and 6?
	I have read the privacy policy and agree
LINK TO PRIVACY POLICY I agree that the personal data collected in the context of this form and in the context of a possible subsequent contact by the Parkinson-Klinik Ortenau will be stored and used for the purpose of answering my request and any follow-up questions. This consent can be withdrawn at any time with effect for the future.

After we have received this electronic registration you will receive the complete treatment contract containing all the required information as well as contract forms for additional services such as accommodation and treatment by the chief physician. We will also notify you of the prospective admission date and contact you by phone.