Fill in the form
Sign and send the declaration
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:


* - 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