Figurkompass – Questionnaire

With “Figurkompass”, we provide you with medical support for weight loss with the “weight loss injection”, initially over a period of 12 months.
After an initial assessment, we measure and evaluate the progress and any side effects on a monthly basis, adjust the dosage if necessary, and determine further therapy.

The “Figurkompass” is billed according to GOÄ (German Schedule of Fees for Physicians).

The costs for the medication (Wegovy or Mounjaro) and the costs for the needles (for Mounjaro) are not included below.

Die Kosten für Medikamente (Sie holen mit dem monatlich ausgestellten Rezept das gewählte Medikament – Wegovy oder Mounjaro – aus der Apotheke): ca. 150 – 300€ pro Monat.

Die beschriebenen Leistungen gelten als vereinbart und die Kosten sind durch Sie zu begleichen, unabhängig davon, ob Ihre Versicherung diese erstattet. Sie bestätigen dies durch Ihre Unterschrift am Ende dieses Formulars.

Eine Individualisierung auf Ihre persönlichen Bedürfnisse, ggfs. optionale Zusatzleistungen können Sie beim Figurkompass Start-Gespräch mit der Ärztin besprechen.

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 information required for invoicing from the patient file 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 this 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 have been informed that my treatment is not dependent on agreeing to the processing operations described above. This consent also applies to claims arising 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 that has taken place up to that point on the basis of this consent.
If the declaration is made as a legal guardian of a minor child, I assure that the other legal guardian also agrees to the above regulations.