1
Fill in the form
2
Sign and send the declaration
3
Make an appointment
If the choice is made for the third or subsequent time in the current calendar year, it should be indicated whether the reason for the choice is: *
Add legal representative
(In the case where the beneficiary is a minor or completely incapacitated)
Data concerning the legal representative:

Legenda:

* - Required field
** - Mandatory field, providing contact details will allow the doctor to contact the patient in order to conduct teleconsultation, as well as complete the registration correctly