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Hattyú u. 14, 5th Floor, 1015 Budapest
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About FirstMed
Contact Us

Patient Registration – FirstMed

Home » Contact FirstMed 24/7 » Patient Registration – FirstMed

Registration forms to get you started as a patient of FirstMed.

Complete the appropriate form/s below or download in PDF format, print, and and return to the FirstMed Offices:

Register as a patient

Medical Release Authorization

Authorization to Collect

Register as a patient

Please note that it is necessary to click both blue fields at the end of each form in order for our colleagues to receive them both.

Please do not write in ‘ALL CAPS’, use Proper Case [e.g. Smith, John]

Download as a PDF here or complete online below:

2. FirstMed Registration Form

"*" indicates required fields

First/Given name*

Middle name

Last/Family name*

Date of birth*

This identifies you in our system.

E-mail*

Mobile Tel.*

ex. +3630-567-8910

Have you visited FirstMed before?

I am an existing patient, please update my record

I’m a new patient, please register

This field is hidden when viewing the form

I am an existing patient, please update my record

Yes

Which details have changed?

Personal details

Address

Private health insurance

Personal identification

Personal details

Name (if different from the above)

First/Given name Middle name Last/Family name

Name before marriage (if different from the above)

First/Given name Middle name Last/Family name

Mother's name before marriage*

First/Given name Middle name Last/Family name

This information is needed for privacy checks as well for you to be able to receive ePrescription. If a false name is given this may casue issues with receiving prescriptions if the same name is not used.

This field is hidden when viewing the form

Mother's name before marriage

This information is needed for privacy checks as well for you to be able to receive ePrescription. If a false name is given this may casue issues with receiving prescriptions if the same name is not used.

Gender*

Male

Female

Citizenship*

Only one. The same as your passport.

City of birth*

This field is hidden when viewing the form

Communication language*

ENG

HUN

If you have international medical insurance the answer must be ENG for invoice processing

Are you a…

Tourist, visiting Hungary for a shorter period

Foreigner, working in Hungary for a longer period

Student

Missionary

None of the above

Address

Residential address*

Street name and address, e.g. Hattyú u. 14, 5th Floor Street address continued (fill if necessary) City ZIP / Postal Code Country

Is this your permanent address?

Yes

No

Permanent address

Street name and address, e.g. Hattyú u. 14, 5th Floor Street address continued (fill if necessary) City ZIP / Postal Code Country

Private health insurance

Do you have private health insurance?*

Yes

No

We are contracted with many private health insurers for direct billing. If you need to pay and claim back from your insurer please let the billers know. All insurance documents need to be viewed and scanned by FirstMed. You must bring your insurance documents with you for your visit.

Would you like to use private health insurance to cover your visit?*

Yes

No

not sure at this moment

Insurance Provider*

Insurance Policy No.*

Insurance card

Please attach the copy of your insurance card, so we can check whether we can accept your policy.

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

This field is hidden when viewing the form

Expiry date

Personal identification

State-required identification

Do you have (valid or expired) TAJ? (Hungarian social security number)*

I have TAJ

No TAJ

If you have a TAJ #, the Hungarian state health insurance, please click yes. With TAJ you can have price reductions on some medication as well as e-prescription at most pharmacies

TAJ number*

If you have a TAJ number please use this. It willl allow for more e-prescriptions as well as state-supported medication prices. FirstMed is a private clinic. We do not accept TAJ for payment options.

Passport number*

If you have a TAJ number please use this. It willl allow for more e-prescription locations as well as state-supported medication prices

Country of passport*

The county of the passport

This field is hidden when viewing the form

Emergency contact

This field is hidden when viewing the form

Name

This field is hidden when viewing the form

Telephone

This field is hidden when viewing the form

The relationship:

Guardian

Family

Friend

Colleague

Other

This field is hidden when viewing the form

Results (Laboratory / Radiology)

Inside/outside lab work, x-ray, ultrasound, and mammography

This field is hidden when viewing the form

Online access to your results

Username (capital letters, no space) Password **

Information regarding prices:*

I accept & understand the pricelist

Click here to review our pricelist.

Comment

Write here if you have any comments or would like to add anything to the above.

FirstMed Privacy Policy*

I accept & understand the privacy policy

Having been sufficiently informed on the subject I consent by my own free will and give authorization to the handling and checking of my involved personal data – in compliance with the Privacy Policy – to the Data Controller.

Marketing Permission (optional)

Yes

From time to time we would like to let you know about special offers, contests, news updates. May we contact you via email? Consent may be withdrawn at any point.

*You should get an email after your registration. FirstMed will never share your email address or any personal information with a third party.

If you cannot find the confirmation email in your inbox – please check the spam folder as well, call us at +36 1 224 9090 for more information. Thank you!

Name

This field is for validation purposes and should be left unchanged.

Medical Release Authorization

Download as a PDF here or complete online below:

Medical Information Release Consent Form

I hereby acknowledge that FirstMed-FMC Kft. may hand over medical documentation related to me to the person and/or in the manner I have designated in this declaration. The medical documentation shall be deemed as handed over to me – in case of personal delivery, by the delivery, in case of an e-mail, by the sending, and in case of registered mail, by the sending. Therefore, as long as my instructions as stated herein are followed, I may not raise any claims against FirstMed-FMC Kft. regarding the handing over of my medical documentation, and I may not claim that FirstMed-FMC Kft. has breached my privacy rights with regard to the disclosure of my medical documentation.

Please check all that apply, then fill in the relevant parts of the form.*
- I DO NOT CONSENT to having my medical records sent by any means. I will always pick them up personally.
- I consent to receiving my medical information at the below e-mail address
- I consent to receiving my medical information at the below mailing address by registered mail
- I consent to having my medical records sent to the below Insurance Company
- I authorize the following person to receive my records on my behalf personally
- I authorize the following person to receive my records on my behalf by email
My name*
First Last
My email address*
Enter Email Confirm Email
My postal address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Name of insurance company
Name of authorized person
First Last
Status of authorized person (friend, family…etc.)
Email of authorized person
Enter Email Confirm Email
Phone of authorized person
Address of authorized person
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Authorization to Collect

Download as a PDF here.

24-hour telephone assistance: +36 1 224 9090

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FirstMed - International Private Clinic

FirstMed is an international, standard healthcare company based in Budapest, Hungary, providing English-language outpatient care. Since its establishment in 1999, the clinic has consistently been recognized as one of the best healthcare centers in the region.

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