Patient Forms – FirstMed

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Forms to get you started as a patient of FirstMed.

Complete the appropriate form/s below or download in PDF format, print, and and return to the FirstMed Offices:

Register as a patient

Medical Release Authorization

Authorization to Collect

Register as a patient

Please note that it is necessary to click both blue fields at the end of each form in order for our colleagues to receive them both.

Please do not write in ‘ALL CAPS’, use Proper Case [e.g. Smith, John]

Download as a PDF here or complete online below:

FirstMed Registration Form

Personal Information
I am an existing patient, please update my record
- Yes
Last/Family name*
First/Given name*
Middle name
Maiden name
Mother's maiden name [Firstname / Lastname]*

This information is needed for privacy checks as well for you to be able to receive ePrescription. If a false name is given this may casue issues with receiving prescriptions if the same name is not used.
Date of Birth*
City of birth*
Citizenship

Only one. The same as your passport.
Gender*
- Male
- Female
E-mail*
State required identification
Do you have TAJ? (Hungarian social security number)*
- I have TAJ
- No TAJ
If you have a TAJ #, the Hungarian state health insurance, please click yes. With TAJ you can have price reductions on some medication as well as e-prescription at most pharmacies
TAJ number*

If you have a TAJ number please use this. It willl allow for more e-prescriptions as well as state-supported medication prices. FirstMed is a private clinic. We do not accept TAJ for payment options.
Passport number*

If you have a TAJ number please use this. It willl allow for more e-prescription locations as well as state-supported medication prices
Country of passport*

The county of the passport
Method of payment
Will you be using international medical insurance to cover your visit?
- Yes
- No
- not sure at this moment
We accept many international medical insurance plans with direct billing. If you need to pay and claim back from your insurer please let the billers know. All insurance documents need to be viewed and scanned by FirstMed. You must bring your insurance documents with you for your visit.
Hidden
Do you have International Medical Insurance
- Yes
- No
Hidden
Insurance Provider
Hidden
Insurance Policy No.
Hidden
Insurance ID No.
Hidden
Expiry date
Mobile Tel.*

ex. +3630-567-8910
Hidden
Communication language*
- ENG
- HUN
If you have international medical insurance the answer must be ENG for invoice processing
Are you a…
- tourist
- student
- missionary
Address
Residential address*
Street name | eg. Hattyú Street type | e.g. utca City ZIP / Postal Code Country
Is this your permanent address?
- Yes
- No
Permanent address
Street name | eg. Hattyú Street type | e.g. utca City ZIP / Postal Code Country
Hidden
Emergency Contact
Hidden
Name
Hidden
Telephone
Hidden
The relationship:
- Guardian
- Family
- Friend
- Colleague
Hidden
Results (Laboratory / Radiology)
Inside/outside lab work, x-ray, ultrasound, and mammography
Hidden
Online access to your results
Username (capital letters, no space) Password **
Information regarding prices:*
- I accept & understand the pricelist
Click here to review our pricelist.
FirstMed Privacy Policy*
- I accept & understand the privacy policy
I hereby declare that I have read and accept the terms of the Privacy Policy of Firstmed-FMC Egészségügyi Szolgáltató Korlátolt Felelősségű Társaság (seat: 1015 Budapest, Hattyú utca 14., company register: 01-09-958986, referred to as “Data Controller”) based on Directive (EU) 2016/679 (GDPR) of the European Parliament and the Council. ű Having been sufficiently informed on the subject I consent by my own free will and give authorization to the handling and checking of my involved personal data – in compliance with the Privacy Policy – to the Data Controller.
Contact Permission (optional)
- Yes
From time to time we would like to let you know about special offers, contests, news updates. May we contact you via email? Consent may be withdrawn at any point.
*You should get an email after your registration. FirstMed will never share your email address or any personal information with a third party.
If you cannot find the confirmation email in your inbox – please check the spam folder as well, call us at +36 1 224 9090 for more information. Thank you!
Name
This field is for validation purposes and should be left unchanged.

Medical Release Authorization

Download as a PDF here or complete online below:

Medical Information Release Consent Form

I hereby acknowledge that FirstMed-FMC Kft. may hand over medical documentation related to me to the person and/or in the manner I have designated in this declaration. The medical documentation shall be deemed as handed over to me – in case of personal delivery, by the delivery, in case of an e-mail, by the sending, and in case of registered mail, by the sending. Therefore, as long as my instructions as stated herein are followed, I may not raise any claims against FirstMed-FMC Kft. regarding the handing over of my medical documentation, and I may not claim that FirstMed-FMC Kft. has breached my privacy rights with regard to the disclosure of my medical documentation.

Please check all that apply, then fill in the relevant parts of the form.*
- I DO NOT CONSENT to having my medical records sent by any means. I will always pick them up personally.
- I consent to receiving my medical information at the below e-mail address
- I consent to receiving my medical information at the below mailing address by registered mail
- I consent to having my medical records sent to the below Insurance Company
- I authorize the following person to receive my records on my behalf personally
- I authorize the following person to receive my records on my behalf by email
My name*
First Last
My email address*
Enter Email Confirm Email
My postal address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Name of insurance company
Name of authorized person
First Last
Status of authorized person (friend, family…etc.)
Email of authorized person
Enter Email Confirm Email
Phone of authorized person
Address of authorized person
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Authorization to Collect

Download as a PDF here.

24-hour telephone assistance: +36 1 224 9090

Contact Us

FirstMed - International Private Clinic

FirstMed is an international, standard healthcare company based in Budapest, Hungary, providing English-language outpatient care. Since its establishment in 1999, the clinic has consistently been recognized as one of the best healthcare centers in the region.

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