Anmeldeformular

Patientin/Patient

Name:

Vorname:

Geburtsdatum:

Geschlecht: w m

Strasse:

PLZ Wohnort:

Tagsüber erreichbar unter:

Privat Festnetz:

Natel:

Geschäft:

Krankheit Unfall

Garant:

Homepage:

Terminvergabe:

Bitte Patient aufbieten Patient meldet sich selber

Dringlichkeit:

normal dringend Notfall (Anmeldung per Tel. unter 061 301 65 40)

Zuweisungsdiagnose:

akute Schmerzenchronische Schmerzen > 3 Monate

Nebendiagnosen:

SchwangerschaftGerinnungsstörungInfektionen (Hep.B, Hep.C,HIV)Kardiale Rhythmusstörungen, AV-Block, QT-Zeit Verlängerung

Allergien:

LatexJodKontrastmittel

Medikation:

AspirinMarcoumarandere Blutverdünner

Labor (bis max. 6 Mt. alt):

Quick/INRTcLcCRP

Berichte, Röntgenbilder, MRI, CT inkl. Befunden:

folgen per Mail,Fax,Postwerden vom Patienten mitgebracht

Anmeldung für:

Konsilium: Beurteilung und Therapievorschlag

Medikamentöse und/ oder Interventionelle Schmerzdiagnostik und -therapie

Gewünschte Intervention:

(aus medicolegalen und medizinischen Gründen fi ndet vor einer Intervention immer eine Erstkonsultation statt, Ausnahme ist der Notfall)

Qutenza

Neuraltherapie

Weitere Massnahmen:

erwünscht, ohne vorhergehende Rücksprache

erst nach Rücksprache: Telefon Mail

Erstkonsultationsbericht (innerhalb einer Woche)

Telefonische Rückmeldung nach der Erstkonsultation gewünscht

Berichtskopie an:

Zuweiser:

Debug

ACF Options:

grid_columns: string
grid_gutter-horz: px string
grid_gutter-vert: px string
grid_default-item-width: 1fr string
base-layout: stacked string
has-header: 1 string
has-bg-img: string
has-footer: 1 string
gallery-slider-id: 1 string
site-gutter-top: 20px string
site-gutter-right: 20px string
site-gutter-bottom: 20px string
site-gutter-left: 20px string
content-max-width: 1200px string
limit-width-nav: 1 string
limit-width-header: string
limit-width-content: 1 string
limit-width-footer: 1 string
content-align: center string
header_gutter-bottom: 25px string
content-gutter-bottom: 25px string
content-item_gutter-top: 0px string
content-item_gutter-bottom: 0px string
content-item_m_gutter-top: px string
content-item_m_gutter-bottom: 0px string
content-item_s_gutter-top: 0px string
content-item_s_gutter-bottom: 0px string
header-bar_padding-top: 40px string
header-bar_padding-right: 0px string
header-bar_padding-bottom: 40px string
header-bar_padding-left: 0px string
header-bar-sticky_padding-top: 25px string
header-bar-sticky_padding-right: 0px string
header-bar-sticky_padding-bottom: 25px string
header-bar-sticky_padding-left: 0px string
header-bar_m_padding-top: 25px string
header-bar_m_padding-right: 0px string
header-bar_m_padding-bottom: 25px string
header-bar_m_padding-left: 0px string
header-bar_s_padding-top: 10px string
header-bar_s_padding-right: 0px string
header-bar_s_padding-bottom: 10px string
header-bar_s_padding-left: 0px string
has-post-teaser-custom: 1 string
post-teaser_: string
post-teaser_type: post string
post-teaser_category: string
post-teaser_count: 6 string
post-teaser_columns: 2 string
post-teaser_sort: date string
post-teaser_order: DESC string
post-teaser_gutter-horz: 25px string
post-teaser_gutter-vert: 25px string
post-teaser_has-color-bg: 1 string
post-teaser_color-bg: #ffffff string
post-teaser_has-color: string
post-teaser_color: #9d6b5d string
post-teaser_has-color-heading: string
post-teaser_color-heading: #9d6b5d string
post-teaser_has-border-top: string
post-teaser_has-border-bottom: string
post-teaser_border-top_type: string
post-teaser_border-top_weight: px string
post-teaser_border-top_color: string
post-teaser_border-bottom_type: string
post-teaser_border-bottom_weight: px string
post-teaser_border-bottom_color: string
post-teaser_equal-height: 1 string
post-teaser_text-align: left string
post-teaser_text-position: underneath string
post-teaser_animation-style: string
post-teaser_overlay-bg-color: string
post-teaser_overlay-bg-alpha: % string
post-teaser_gutter-inner_top: 20px string
post-teaser_gutter-inner_right: 10px string
post-teaser_gutter-inner_bottom: 20px string
post-teaser_gutter-inner_left: 20px string
post-teaser_text-gutter-top: 0px string
post-teaser_text-gutter-right: 0px string
post-teaser_text-gutter-bottom: 20px string
post-teaser_text-gutter-left: 0px string
post-teaser_text-gutter-inner-top: % string
post-teaser_text-gutter-title-content: 0px string
post-teaser_img-gutter-top: 0px string
post-teaser_img-gutter-right: 0px string
post-teaser_img-gutter-bottom: 10px string
post-teaser_img-gutter-left: 0px string
post-teaser_img-max-height: px string
post-teaser_display-title: 1 string
post-teaser_display-category: string
post-teaser_display-default-category: string
post-teaser_display-excerpt: 1 string
post-teaser_display-field: string
post-teaser_display-field-name: string
post-teaser_display-field-position: string
post-teaser_pagination: 1 string
post-teaser_lazyload: 1 string
post-teaser-custom_: string
post-teaser-custom_type: post string
post-teaser-custom_category: string
post-teaser-custom_count: 6 string
post-teaser-custom_columns: 3 string
post-teaser-custom_sort: name string
post-teaser-custom_order: ASC string
post-teaser-custom_gutter-horz: 25px string
post-teaser-custom_gutter-vert: 30px string
post-teaser-custom_has-color-bg: string
post-teaser-custom_color-bg: string
post-teaser-custom_has-color: string
post-teaser-custom_color: string
post-teaser-custom_has-color-heading: string
post-teaser-custom_color-heading: string
post-teaser-custom_has-border-top: string
post-teaser-custom_has-border-bottom: string
post-teaser-custom_border-top_type: string
post-teaser-custom_border-top_weight: px string
post-teaser-custom_border-top_color: string
post-teaser-custom_border-bottom_type: string
post-teaser-custom_border-bottom_weight: px string
post-teaser-custom_border-bottom_color: string
post-teaser-custom_equal-height: 1 string
post-teaser-custom_text-align: center string
post-teaser-custom_text-position: overlay string
post-teaser-custom_animation-style: 1 string
post-teaser-custom_overlay-bg-color: #000000 string
post-teaser-custom_overlay-bg-alpha: 70% string
post-teaser-custom_gutter-inner_top: 0px string
post-teaser-custom_gutter-inner_right: 0px string
post-teaser-custom_gutter-inner_bottom: 0px string
post-teaser-custom_gutter-inner_left: 0px string
post-teaser-custom_text-gutter-top: 0px string
post-teaser-custom_text-gutter-right: 0px string
post-teaser-custom_text-gutter-bottom: 0px string
post-teaser-custom_text-gutter-left: 0px string
post-teaser-custom_text-gutter-inner-top: 30% string
post-teaser-custom_text-gutter-title-content: 0px string
post-teaser-custom_img-gutter-top: 0px string
post-teaser-custom_img-gutter-right: 0px string
post-teaser-custom_img-gutter-bottom: 0px string
post-teaser-custom_img-gutter-left: 0px string
post-teaser-custom_img-max-height: px string
post-teaser-custom_display-title: 1 string
post-teaser-custom_display-category: 1 string
post-teaser-custom_display-default-category: string
post-teaser-custom_display-excerpt: string
post-teaser-custom_display-field: string
post-teaser-custom_display-field-name: string
post-teaser-custom_display-field-position: string
post-teaser-custom_pagination: 1 string
post-teaser-custom_lazyload: 1 string
logo_: string
logo_standalone-source: image string
logo_standalone-template: string
logo_standalone: string
logo_standalone-position: left string
logo_standalone-inherit: string
logo_height-standalone: 100px string
logo_color-svg-standalone: string
logo_position: left string
logo_header-source: image string
logo_default: image string
logo_height: 100px string
logo_color-svg: string
logo_header-spacer: string
logo_header-sticky-source: default string
logo_header-sticky: image string
logo_height-sticky: 100px string
logo_color-svg-sticky: string
logo_header-mobile-source: default string
logo_header-mobile: string
logo_height-mobile: 60px string
logo_color-svg-mobile: string
logo_header-mobile-sticky-source: default string
logo_header-mobile-sticky: string
logo_height-mobile-sticky: 60px string
logo_color-svg-mobile-sticky: string
logo_header-tablet-source: default string
logo_header-tablet: string
logo_height-tablet: 60px string
logo_color-svg-tablet: string
logo_header-tablet-sticky-source: default string
logo_header-tablet-sticky: string
logo_height-tablet-sticky: 60px string
logo_color-svg-tablet-sticky: string
logo_side-nav-source: image string
logo_side-nav: image string
logo_height-side-nav: 100px string
logo_color-svg-side-nav: string
typo_default_size: 16px string
typo_default_line-height: px string
typo_paragraph-gutter: px string
typo_heading_size: 30px string
typo_heading_weight: normal string
typo_heading_line-height: 33px string
typo_heading_gutter-before: 0px string
typo_heading_gutter-after: 25px string
typo_subheading_size: 20px string
typo_subheading_weight: normal string
typo_subheading_line-height: px string
typo_subheading_gutter-before: 0px string
typo_subheading_gutter-after: 10px string
has_typo_s: string
has_typo_m: string
font-source: default string
default-font: Helvetica, Arial, sans-serif string
font-use-alternate: string
icon_use-font: string
icon_sizing: string
icon_size-abs: px string
icon_size-rel: x string
header_type: stretch string
header_height: 200px string
header_m_height: 160px string
header_s_height: 120px string
header_boxed: 1 string
header_content: image string
header_slider-id: string
header_image-type: background-image string
header_image-fixed: string
header_image-src: string
footer_type: stretch string
footer_boxed: 1 string
footer_: string
footer_inner_gutter-top: 10px string
footer_inner_gutter-right: 0px string
footer_inner_gutter-bottom: 0px string
footer_inner_gutter-left: 16px string
footer_source: page string
footer_widget_spacing: space-between string
footer_widget_width: 320px string
footer_widget_max-width: px string
footer_widget_gutter-horz: 25px string
footer_widget_gutter-vert: 30px string
footer_content-page: 541 string
color_page-bg: #ccb2a8 string
color_text: #2d1004 string
color_heading: #ffffff string
color_subheading: #ffffff string
color_link: #2d1004 string
color_link-highlight: #ffffff string
color_: string
color_header-bg: #ccb2a8 string
color_nav: #2d1004 string
color_nav-highlight: #9d6b5d string
color_nav-bg: #ffffff string
color_nav-bg-alpha: 90% string
color_nav-sticky: #2d1004 string
color_nav-sticky-highlight: #9d6b5d string
color_nav-sticky-bg: #ffffff string
color_nav-sticky-bg-alpha: 90% string
color_menu-toggle: #9d6b5d string
color_menu-toggle-sticky: #9d6b5d string
color_nav-s-link: string
color_nav-s-hover: #2d1004 string
color_submenu: #9d6b5d string
color_submenu-highlight: #000000 string
color_submenu-bg: #FFFFFF string
color_submenu-bg-alpha: 100% string
color_submenu-sticky: #9d6b5d string
color_submenu-sticky-highlight: #000000 string
color_submenu-sticky-bg: #FFFFFF string
color_submenu-sticky-bg-alpha: 100% string
color_content-bg: #ccb2a8 string
color_content-bg-alpha: 100% string
color_footer: #ffffff string
color_footer-heading: #ffffff string
color_footer-link: #ffffff string
color_footer-link-highlight: #9d6b5d string
color_footer-bg: #ccb2a8 string
color_rs_slides-bg: #ffffff string
color_rs_thumbs-bg: #ffffff string
color_icon: #ffffff string
color_alt-link: #9d6b5d string
color_alt-link-hover: #000000 string
nav-sticky: 1 string
l-nav_type: inline string
l-nav_subnav-type: hoverblock string
m-nav_type: inline string
m-nav_subnav-type: hoverblock string
s-nav_type: side-nav string
s-nav_subnav-type: unfolded string
s-nav_menu-icon: string
header-bar_inline-item-spacing: flex-end string
header-bar_inline-gutter-before: 0px string
header-bar_inline-gutter-after: 0px string
header-bar_inline-gutter-item: 40px string
side-nav_direction: right string
side-nav_item-min-height: 50px string
side-nav_item-padding-top: 5px string
side-nav_item-padding-right: 15px string
side-nav_item-padding-bottom: 5px string
side-nav_item-padding-left: 20px string
side-nav_item-first-padding-top: 20px string
side-nav_item-last-padding-bottom: 5px string
text-block_gutter-inner_top: 25px string
text-block_gutter-inner_right: 0px string
text-block_gutter-inner_bottom: 25px string
text-block_gutter-inner_left: 0px string
text-block_equal-height: 1 string
text-block_color-bg: string
text-block_has-border-top: string
text-block_has-border-bottom: string
image-block-defaults_height: px string
image-block-defaults_max-height-m: px string
image-block-defaults_max-height-s: px string
maps-block-defaults_height: 500px string
maps-block-defaults_height-tablet: 400px string
maps-block-defaults_height-mobile: 300px string
single-post_layout: columns string
single-post_col-count: 2 string
single-post_column-ratio: plusleft string
single-post_content-col1: imagery string
single-post_content-col2: text string
single-post_content-col3: string
single-post_title-position: above string
single-post_img-fallback: postimage string
single-post_inherit-settings: string
single-post_: string
single-post_first-child-offset: px string
single-page_layout: default string
single-page_col-count: string
single-page_column-ratio: string
single-page_content-col1: string
single-page_content-col2: string
single-page_content-col3: string
single-page_title-position: string
single-page_img-fallback: string
single-page_inherit-settings: string
single-page_: string
single-page_first-child-offset: px string
single-custom_layout: default string
single-custom_col-count: string
single-custom_column-ratio: string
single-custom_content-col1: string
single-custom_content-col2: string
single-custom_content-col3: string
single-custom_title-position: string
single-custom_img-fallback: string
single-custom_inherit-settings: string
single-custom_: string
single-custom_first-child-offset: px string
element_hr_type: solid string
element_hr_weight: 1px string
element_hr_color: #cbb1a7 string
element_ul_item-char: > string
element_ul_item-size: 0.95x string
element_ul_textindent: ch string
element_ul_item-gutter: px string
element_ul_item-color: string
post-nav-order: normal string
collapsable_use: 1 string
collapsable_default-title: Mehr Informationen... string
collapsable_icon-type: img string
collapsable_icon-img-open: image string
collapsable_icon-img-close: image string
collapsable_icon-text-open: mehr ... string
collapsable_icon-text-close: weniger ... string
collapsable_duration: 500ms string
collapsable_cursor-open: s-resize string
collapsable_cursor-close: n-resize string
feature_flexbox: 1 string
feature_svg-injector: 1 string
feature_svg-color-selecor: #farbe path string
feature_svg-color-property: fill string
feature_menu-toggle_svg-color-selecor: rect string
feature_menu-toggle_svg-color-property: fill string
feature_font-smoothing: 1 string
plugin-cf7: string
plugin-rs: 1 string
debug-msg: string
fields-version: 1.91 string