Contract

Important


If an under age has an appointment (initial or recurring appointment), the patient must come to the clinic accompanied by a legal representative (the legal representative is parents, guardians or any persons, for whom was effectuated a power of attorney from parents, certified by a lawyer) to sign a medical agreement, consent to medical intervention and processing of personal data in the presence of an employee of the medical center, as well as for direct presence during the appointment.


You must take with you the original documents that were indicated when filling out the form: the passport of the legal representative and the child’s birth certificate.


In the case of guardianship or a power of attorney issued by the parents for the accompanying person, it is also necessary to provide the originals of these documents.

Clinic
Clinic *
  • GMS Clinic Smolenskaya
  • GMS Clinic Yamskaya
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A patient
Гражданство *
  • Foreign citizen adult
  • Foreign citizen child
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Личные данные

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Invalid e-mail
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Passport

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Actual registration address

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Actual residence address

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Личные данные

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Invalid e-mail
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Passport

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Actual residence address

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Адрес проживания

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Company/college of the patient *

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* This section must be filled in if PCR is being submitted.

Parent / Guardian

Личные данные

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Invalid e-mail
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Passport

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Field required to be entered
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Actual registration address

Field required to be entered
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Actual residence address

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Field required to be entered
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Company/college of the patient *

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* This section must be filled in if PCR is being submitted.