Travel Medicine Questionnaire - Avismed

Reisemedizin

Updates

Basic data, travel destination, anamnesis
Costs and assignment of invoice

Please ensure that your details match the information on your health insurance card (so that we can correctly identify you).

Questions marked with “*” are mandatory.

First name

Last name

Date of birth

Gender

How wonderful that you are planning a trip! To ensure you can enjoy your time on the road carefree and healthy, we want to provide you with the best possible medical advice and support.

Please fill out this questionnaire in advance. Your information will help us prepare accordingly before the appointment so that we can advise you in a targeted manner.

We are happy with you about your upcoming trip – and to send you well prepared on your way!

Travel destination

Start of travel

End of travel

Reisezweck

Privat

Beruflich

Travel condition

Hotel- oder Badeurlaub

Trekking-Urlaub

Langzeitaufenthalt (länger als 6 Wochen)

Enge soziale Kontakte

Other countries of travel
Are there any other countries of travel on this trip?
Please enter the other countries of travel together with the arrival date as text

Do you currently feel healthy?

Yes

Healthy Other

Is there a chicken egg white allergy/intolerance?

Yes

Are there any other allergies / intolerances?

Household products

House dust

Insect venom (bees, wasps)

Latex / rubber

Medications

Metals

Food

Plasters

Pollen

Animal hair

Other

Allergies Other

Are states of weakness known on the occasion of injections/blood collections?

Yes

Do/did you or family members have nerve diseases or a seizure disorder?

Yes

Do/did you suffer from a chronic or malignant disease?

Yes

Disease Other

Do you take medication regularly?

Yes

Medications Other

Have you had vaccinations in the last 4 weeks?

Yes

Vaccinations Other

Is there a pregnancy or is one planned?

Yes

Are you HIV positive?

Yes

I do not want to answer (please point this out in a personal conversation with the doctor if you are HIV positive)

The travel medicine consultation is charged according to GOÄ (fee schedule for doctors) and is composed as follows:

the travel medicine consultation: €67.01
the issuing of a prescription for the vaccines: €3.15 per prescription
the vaccination of the vaccine: €10.72 per vaccination
the 2nd vaccination in the same session: €6.70
additional costs for the vaccines (to be paid directly by you at the pharmacy)

The timeline and the necessary steps are described on our website under “Services / Travel Medicine”.

The services described are considered agreed and the costs are to be paid by you, regardless of whether your insurance reimburses them. You confirm this with your signature at the end of this form.

Invoice Assignment

We work with our partner AvisCode GmbH for invoicing and billing.
If you have any questions about billing, please contact us: rechnung@avismed.de

Your data will only be passed on on the basis of your consent and in compliance with the GDPR and the medical confidentiality obligation in accordance with § 203 StGB, which also applies to all AvisCode employees.

Thank you for your trust
Your Avismed Team

Please read the Information on data protection according to Art. 13 and 14 GDPR.

I agree with the

Disclosure of the personal data required for billing and enforcement of the fee claims (e.g. name, date of birth, address, treatment and examination data) to AvisCode GmbH. I am informed that AvisCode uses external technical service providers to process this data, who act exclusively on behalf of AvisCode GmbH and are contractually obliged to comply with the applicable data protection regulations in accordance with Art. 28 GDPR
Commissioning AvisCode by my doctor to create, send and manage invoices and payment reminders in my name, including the use of an online portal to provide this information
Disclosure of the information from the patient file required to justify the invoice to AvisCode and – in the event of a dispute – to courts or legal advisors. I release my doctor and the employees of AvisCode from the obligation of confidentiality to that extent
the release of Avismed from the obligation of confidentiality towards the external partner should there be different opinions in the course of the claim

I am informed that my treatment is not dependent on consent to the processing operations described above. This consent also applies to claims from future treatments. This declaration is made voluntarily.
The consent can be revoked at any time with effect for the future. The revocation does not affect the legality of the processing carried out up to that point on the basis of this consent.
If the declaration is submitted as a legal guardian of a minor child, I assure that the other legal guardian also agrees to the above regulations.

You will receive this declaration of consent and the data protection declaration by email if you agree at the end of this form.

Ich bin mit Abtretung der Forderungen und dem beschriebenen Umgang mit meinen personenbezogenen Daten einverstanden:

Ja, ich erkläre mich einverstanden und bestätige meine Einwilligung mit meiner Unterschrift am Ende des Formulars

Nein, ich bin nicht einverstanden (die Rechnungsstellung erfolgt dann direkt über Avismed)

I would like to receive a copy of this form (and the information on data protection) as a PDF by email (the PDF is in german, even though this questionnaire is in english for your convenience)

Yes

Email for form submission

Signature Patient/in or legal representative/in – I commission the services ticked above and agree to the invoice processing via AvisCode:

Es ist ungewohnt mit der Maus zu unterschreiben. Keine Sorge – Ihre Unterschrift ist trotzdem genauso gültig wie auf Papier.

Signature Patient/in or legal representative/in – I commission the services ticked above:

Sign Here