Application for registration on the practice list of a family physician

Name of the family physician......................................................................................................................

My name	......................................................................................................................

Personal identification code ......................................................................................................................

Address of residence according to the Estonian Population Register ......................................................

Contact information (phone, address) ........................................................................................................

Please register me on the practice list.

My previous family physician was .............................................................................................................

Close relatives or relatives by marriage that are on the practice list of the family physician:

....................................................................................................................................................................

(name, personal identification code, degree of affinity)

(note if the chosen family physician has more than 2,000 persons on their practice list)

I am choosing a practice list (note X on the right line):

-	for the first time	.............

-	to change my practice list	.............

Signature	........................................

Date	........................................

Filled in by the family physician:

-	I agree	.............

-	I decline	.............

  Reason for declining ..................................................... 

Name of the family physician	................................................................................................

Signature of the family physician	................................................................................................

Date	...................................