young+co » General Practice Prague 6

Online registration

If you have Czech public health insurance and wish to use our services on a regular basis then we recommend that you register with us. Registration gives you access to a wider range of services and better prices than you have access to as a non-registered patient.

If you do not have Czech health insurance but wish to use our services on a regular basis as a private client (with or without reimbursement from a health insurance company), you can save time before your first visit by filling in this form also.

After you complete and send the form below to us, we will call you back (on the number that you specify) to make an appointment for your initial examination. This is required as part of the registration process.

When you come for your initial examination please bring with you any medical records that you may have and/or details of medication that you use.

Registration form

Required fields are marked with an asterisk (*)

First name(s):*

Surname:*

Title (Ms., Mr., Mrs., Dr. etc.):

Maiden name (surname at birth) (if different from your current surname):

"Birth number" ("rodné číslo") as issued by the Czech authorities (if you have one):

Number on health insurance card (as issued by Czech public health insurer) - if different from "birth number" or if you have no "birth number"

Date of birth:*

Marital status (single, married, divorced, widowed):

Country of citizenship:*

Address (street, number, town/city, postal code):*

Alternative address (e.g. in home country), if relevant (street, number, town/city, postal code):

Email address:*

Mobile phone (or other telephone contact):*

Home telephone (evenings):

Work telephone (daytime):

Health insurance company (if any):

If you are employed, please also fill in this section:

Name of employer:

Address of employer (street, number, town/city, postal code):

Your function / position / profession:

How did you hear about us? (personal recommendation, press advert, internet search, internet other, ...):*

I give my consent for my personal data to be recorded in line with the requirements of Act No. 101/2000 Coll., as amended*

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