Loan Equipment Agreement – Avismed – Ihr Hausarzt in Hanau

Leihgerätevereinbarung

Please ensure that your details match the information on your health insurance card (so that we can correctly identify you).

Questions marked with “*” are mandatory.

First name

Last name

Date of birth

Gender

The Avismed general practice provides you with the following device:

Long-term ECG

Long-term blood pressure measurement

Polygraphy

The loan period begins with the issue of the loan device and must be returned by the agreed date (usually the following working day).
You undertake to take special care in handling the loan device. Should the loan device be damaged due to improper handling, you will be liable for the damage caused. This also applies to loss.
Any damage (or loss) will be reported immediately to the Avismed general practice.

I would like to receive a copy of this form as a PDF to the following email address (the PDF is in german, even though this questionnaire is in english for your convenience)

Yes

Email for form submission