First name*
Last name*
Date of birth (DD.MM.YYYY)*
Address Line 1*
Address Line 2
Postal code *
City*
Country* SwitzerlandAfghanistanCentral African RepublicSouth AfricaAlbaniaAlgeriaGermanyAndorraAngolaAnguillaSaudi ArabiaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBangladeshBarbadosBahrainBelgiumBelizeBeninBermudaBelarusBoliviaBotswanaBhutanBosnia and HerzegovinaBrazilBruneiBulgariaBurkina FasoBurundiCayman IslandsCambodiaCameroonCanadaCanary IslandsCape VerdeChileChinaCyprusColombiaCongoDemocratic Republic of CongoCook IslandsNorth KoreaSouth KoreaCosta RicaIvory CoastCroatiaCubaDenmarkDjiboutiDominicaEgyptUnited Arab EmiratesEcuadorEritreaSpainEstoniaUnited StatesEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceGabonGambiaGeorgiaGhanaGibraltarGreeceGrenadaGreenlandGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauEquatorial GuineaGuyanaFrench GuianaHaitiHawaiiHondurasHong KongHungaryIndiaIndonesiaIranIraqIrelandIcelandIsraelItalyJamaicaJan MayenJapanJerseyJordanKazakhstanKenyaKyrgyzstanKiribatiKuwaitLaosLesothoLatviaLebanonLiberiaLiechtensteinLithuaniaLuxembourgLibyaMacauMacedoniaMadagascarMadeiraMalaysiaMalawiMaldivesMaliMaltaIsle of ManNorthern Mariana IslandsMoroccoMarshall IslandsMartiniqueMauritiusMauritaniaMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontserratMozambiqueNamibiaNauruNepalNicaraguaNigerNigeriaNiueNorfolk IslandNorwayNew CaledoniaNew ZealandOmanUgandaUzbekistanPakistanPalauPalestinePanamaPapua New GuineaParaguayNetherlandsPeruPhilippinesPolandPolynesiaPuerto RicoPortugalQatarDominican RepublicCzech RepublicReunionRomaniaUnited KingdomRussiaRwandaWestern SaharaSaint LuciaSan MarinoSolomon IslandsEl SalvadorWestern SamoaAmerican SamoaSao Tome and PrincipeSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSomaliaSudanSri LankaSwedenSwitzerlandSurinameSwazilandSyriaTajikistanTaiwanTongaTanzaniaChadThailandTibetEast TimorTogoTrinidad and TobagoTristan da CunhaTunisiaTurkmenistanTurkeyUkraineUruguayVanuatuVatican CityVenezuelaVirgin Islands (US)British Virgin IslandsVietnamWake IslandWallis and FutunaYemenYugoslaviaZambia
Phone number*
Email address *
Relationship with patient
Email address
Substance and/or behavioural dependency. Please specify:
Alcohol
Cannabis
Opiates
Cocaine
Psychotropic medication (tranquilizers, etc.)
Tobacco
Other
Mental health issues. Please specify (depression, trauma, anxiety, stress, burn-out, etc.) Veuillez préciser
Other Please specify
Are you currently seeing any health professional(s), e.g. psychiatrist, GP, therapist, etc?
Do you authorize us to contact the professionals mentioned above? This will help make a swift transition and give us a head start on your treatment. YesNo
Medical or surgical problems
Current state of health (please specify any current physical illnesses and/or injuries that will require attention)
Total current medication (please fill the table with all medication and nutritional complements you are taking, dosage and regimen. It’s important you state all medication as to guarantee your comfort but, most importantly, your safety)
Name
Type (pill, syrup, etc)
Dosage morning
Dosage noon
Dosage evening
Dosage Bedtime
Allergies (e.g., medication, food, other)
Intolerances (e.g., food, other)
Aversion (e.g., food)
Special diet (e.g., no pork, halal, vegan, no gluten, no fish, no seafood, no shellfish, other)
Other specific requirements
How did you learn about Clinic Les Alpes?
I have read the data protection policy established by Clinique Les Alpes SA.
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