Patient Registration – FirstMed

Registration and authorizatioon forms to get started as a patient of FirstMed, or let us know about any changes in your personal or other details.

Registration forms for patients at FirstMed

Please complete and submit all necessary forms below, one tab at a time. Use proper case (e.g., John Smith) and DO NOT USE ALL CAPS!

Please fill out the online registration form below to provide us with your details or notify us of any changes to them. Alternatively, you can download the registration form as a PDF and return it to our clinic after you have completed it.

Note that this form is intended for patient registration purposes only. To book an appointment, please use our contact form.

Patient Registration Form

Fill in the online form below to specify how you would like to receive your medical information. Alternatively, download as a PDF here, and return the complete form to our clinic.

Medical Information Release Consent Form

Complete this form regarding the handing over of your medical documentation. After you submit the form, a confirmation page will appear, and you will receive an email. If you don't get a confirmation, ensure all fields were filled out correctly. We will respond to your request within one business day. In case of any issues, call us at +36 1 224 9090.

Use regular capitalization, NOT ALL CAPS.

"*" indicates required fields

Consent of medical information release*

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. 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 name, and middle name (if there is one) e.g. Michael Peter Last name (family name) e.g. Smith

My email address*

My postal address

Street address with house and apartment number City County / State / Region ZIP / Postal Code Country

Name of insurance company

Name of authorized person

First name, and middle name (if there is one) e.g. Michael Peter Last name (family name) e.g. SmithLast name (family name) e.g. Smith

Status of authorized person (friend, family...etc.)

Email of authorized person

Phone of authorized person

International format, e.g.: +3630-567-8910

Address of authorized person

Street address with house and apartment number City County / State / Region ZIP / Postal Code Country

Download and fill in the ‘Authorization to Collect’ form to allow someone to collect your personal medical documents, prescriptions, or laboratory results from FirstMed. The document must be signed by both you and your authorized representative in the presence of two witnesses.

To protect each other’s health, we kindly ask that you wear a mask during your visit if you have respiratory symptoms (runny nose, sore throat, cough) or fever.

We are currently experiencing phone issues

Please email us at phonenurse@firstmedcenter.com or reach us via chat on our homepage in the lower right corner of this website.

Whatsapp: +36 70 620 5992

Patient Registration – FirstMed

Registration forms for patients at FirstMed

Please complete and submit all necessary forms below, one tab at a time. Use proper case (e.g., John Smith) and DO NOT USE ALL CAPS!

Patient Registration Form

Personal details

Address

Contact details

Private health insurance

Personal identification

Privacy and marketing

Important information

Medical Information Release Consent Form

24-hour telephone assistance: +36 1 224 9090

International Private Clinic network

Contact us

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