Registration form - KTK Pediatric Day Clinic in Liestal

Familienname

Location selection*

Details of the child

Family name*

First name of the child*

Date of birth*

Girl/Boy*

Contact parents

Surname / First name Father

Job

Surname / First name Mother

Job

Private / Mobile phone

Telephone Business

E-mail address

Street, no.*

ZIP CODE*

Place*

Health insurance

Card no. (Starts with 807...)

Paediatrician

Paediatrician address

How did you hear about the Kindertagesklinik?

Do you already have an appointment?*

Appointment on

You agree that KTK Kindertagesklinik Liestal AG may obtain the necessary patient files from the previously treating doctor/hospital for the purpose of further treatment.

Declaration of consent for obtaining information

I have read the AGB and the Data Protection Declaration and I agree to their validity.

If the treatment including medication is not covered by insurance, you undertake to pay the costs incurred.

Declaration of consent to the disclosure of information

Oristalstrasse 87a, 4410 Liestal

Käppelibodenweg 44, 4132 Muttenz

Poststrasse 8, 4460 Gelterkinden

+41 61 927 94 27

info@ktk.ch

ktk.ch

Parking in Liestal
Free parking is available on the 2nd floor of the parking garage.

Emergency numbers

Öffnungszeiten:

Opening Hours Liestal
Opening Hours Muttenz
Opening Hours Gelterkinden

Appointments by phone reservation

Scheduling

Please arrive punctually at the agreed appointment, we are endeavor to keep waiting times to a minimum. Appointments that are not canceled 24h in advance will be charged.

We also ask for your understanding if it is not possible for us to to examine the unannounced siblings additionally. Should it is an emergency, we will charge an emergency rate.