Signup

Our team at canncura is pleased that you have decided to seek cannabis therapy from us. Together with our medical team, we would like to accompany and support you individually. In order to include you in our internal patient database, we require the information requested in this master data sheet. Your data will be treated with the utmost care and will only be accessible to our medical staff. Disclosure of any information is strictly prohibited within the framework of doctor-patient confidentiality.

Please make sure that your data is correct, as it must be identical to the data on your identity card/passport. Any medical documents, for example prescriptions, will only remain valid if the personal data match completely.

I hereby confirm that all my personal data is correct.

Username

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Password

•  kleinschreibung & Grosschreibung
•  Nummer (0-9)
•  Sonderzeichen (+-!@#$%^&*)
•  >10 Zeichen

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repeat Password

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Email

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First name

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Last name

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Gender

Gender female male divers

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Birthday

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City

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Street & Nr

Street & Nr

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Birthplace

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Language

Language German English

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Mobile number

Please Choose 0151 0152 015566 015678 0157 0159 0160 0162 0163 0170 0171 0172 0173 0174 0175 0176 0177 0178 0179

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(All fields are required)

Health insurance

Private or Statutory health insurance? Statutory health insurance Private health insurance

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Do you have an authorised cost reimbursement declaration from your health insurance company? (proof required)

Do you have an authorised cost reimbursement declaration from your health insurance company? (proof required) yes no

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Do you have a legal guardian?

Do you have a legal guardian? yes no

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Anything else you would like to share?

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Declaration of consent regarding data protection

Dear patient,

We require your consent for the processing of your data and services for our treating physicians, the billing of services rendered and for the processing of your data for research purposes. You explain I hereby expressly consent to the following:

1. Disclosure of all data related to your treatment, in particular name, address, date of birth, treatment data, Treatment courses for the purpose of billing and assertion to canncura GmbH, Charlottenstr. 61, 51149 Cologne or a subsidiary.

2. Evaluation of your anonymized data for research purposes and if necessary, forwarding of your data to universities in anonymised form. Third parties do not have access to personal documents. In the Your name will also not be disclosed to the publication of the results of the study.

3. Assignment of the claims resulting from the treatment to canncura GmbH.
4. passing on all personal data collected in connection with this master data collection for the initial presentation to the attending physician.

I hereby give my consent for data processing and signup:

Data protection

TOS

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