Own care request

CK Klinikerna Kirurgi,

Saltsjö-Boo

To request a visit, please fill out this form. Once we have assessed your care request, you will receive a notification regarding further processing. If you have not heard from us within 14 working days, please contact us at CK Klinikerna Kirurgi.

Social security number

First name

Last name

Street address

Postal code and postal address

Phone number

E-mail

Primary Health center

Desired investigation or action

Colonoscopy Breast reduction/Breast reduction Abdominoplasty/Hanging tummy Vasectomy Hernia Gallstone Obesity surgery

Describe your problems

Length

Weight

Do you take medications?

Yes No

If yes

Do you have any known illnesses?

Yes No

If yes

Have you sought care before for the same problem?

Yes No

If yes

Are you on sick leave?

Yes No

If you answered yes,

Own care request

CK Klinikerna Kirurgi,

Saltsjö-Boo

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