Healthcare provision agreement

Would you like to become our patient?

We are accepting new patients into our general practice for adults. Submit the form as a request; we will review it and then contact you with the next step.

Go to the form

How the care agreement is concluded

The online form is the first step, not the agreement itself.

If you would like general outpatient care with our practice, submit the registration form. After reviewing the request, we will arrange an in-person visit with you.

Submitting the form by itself does not conclude a healthcare agreement and does not create a legal relationship between the patient and the healthcare provider.

At the in-person visit, the agreement is concluded in the form permitted by the applicable rules and available electronic authorisation.

The agreement may be concluded:

electronically through the practice information system and authorised using an identity card or residence document with an electronic chip,
on paper if the patient does not have the relevant electronic document or another obstacle prevents electronic authorisation.

The agreement data are entered into the register of healthcare provision agreements maintained by the National Health Information Centre (NCZI).

The agreement generally takes effect on the first day of the following calendar month. If the patient has no other effective agreement, or a statutory exception applies, it may take effect on the day it is entered in the register.

When a new agreement is concluded, the previous agreement ends according to the register rules. The previous provider then transfers the health records to the new provider in accordance with applicable law.

After conclusion you receive confirmation of the agreement; for a paper agreement you receive a copy after it has been entered in the register.

Complete the online request

Provide identification, contact and insurance details and information about your previous general practitioner.

Wait for the practice to review it

After checking the details, we will contact you and arrange an in-person visit.

Conclude the agreement in person

The agreement is authorised electronically or prepared on paper if electronic authorisation is not possible.

What to bring to the in-person visit

An identity card with an electronic chip (or a residence document with a chip) and your health-insurance card.

Entry in the NCZI agreement register

Registration form

Request to join the practice

Basic details

Title — optional

First name

Last name

Birth number

Permanent address

Street and number

Postal code

City

Temporary address — if applicable

Optional. Fill in only if different from your permanent address.

Street and number

Postal code

City

Contact details

Phone

Health insurance

Všeobecná zdravotná poisťovňa

DÔVERA health insurance

Union health insurance

Previous general practitioner

Provide the name and address of the doctor you are transferring from.

Doctor name

Practice address – street and number

Postal code

City

Declarations and consent

I consent to the processing of personal data for registration and the provision of healthcare.

I understand that the agreement is generally concluded for at least six months; an earlier change may depend on a statutory exception.

I declare that the information provided is true and that I am registering freely and seriously.

We use the form data to review your request to join the practice and for subsequent communication with you.