Application Form

* This information is mandatory.


As of January 1st, 2022, all service providers in the healthcare sector are legally obliged to send their patients a copy of the invoice.

In the event of an accident, please fill out the following fields as well


How did you hear about us?*

Were reviews on the internet (e.g. Google reviews) important to you?*


 My physiotherapist is authorised by me:

  • to exchange medical data in connection with my treatment with the referring and treating physicians as well as medical officers of the funding agencies.  • to forward the necessary personal treatment data to the billing institution and to the institution responsible for any debt collection, as well as to the appointed lawyer and to the competent state authorities in the event of non-payment of the treatment bill.   • to create non-public lists of defaulters, which he/she may exchange with other physiotherapists.

I will be billed privately (without entitlement to reimbursement by health insurance companies) for any agreed treatment appointments which I do not attend and which have not been cancelled at least 24 hours before the appointment. All treatment costs that are not paid by my insurance/ health insurance company will be borne entirely by myself.

 Swiss law is applicable.


In order to examine you thoroughly and specifically, we need some information from you. If a question is unclear, simply leave it out. All information is voluntary. We will look at them together later. If you do not wish to fill out this additional form, please click here to go to the "Submit" button. Thank you!

 Have you ever been diagnosed with any of the following conditions?  Please select.



Have you felt down, hopeless, or depressed in the past month?

Have you not been interested in or found pleasure in anything in the past month?

Have you ever been threatened hurt or intimidated by your partner or someone close to you?


Other allergies that may be important to the treatment?

Are you receiving treatment from any of the following professionals?


Last examination date:

In the last three months, have you been treated for any of the above occupational conditions?


Please list all surgeries performed on you and each hospitalization with both the reason and approximate date:







Please list any serious injuries for which you required treatment (e.g. broken bones, ligament injuries) and the approximate date of the injury:







Have any of your family members (parents, siblings) ever been treated for any of the following conditions? Please select.

Which of the following medications have you taken in the past week?


Please list the medications you are currently taking as prescribed by your doctor (tablets, injections, medication patches, etc.):

Drinks and Tobacco

How much coffee or other caffeinated beverages do you consume per day?

How many cigarettes do you smoke per day?

For how many years?

No smoking since?

How many days per week do you drink alcohol?

How many glasses of beer, wine or similar do you drink on these days?

Please select current complaints that are new, unusual or atypical:

Are there any additional information that might be relevant to your medical evaluation?