Menu
Contact
Emergencies
Maennerarzt.ch
DE
EN
For patients
Make an appointment
Hospitalization
Our doctors and urologists
Erweiterte Hilfe & Beratung
Broschüren & Flyer
For doctors & referrers
Downloads
Tumorboard
Therapies & Treatments
Fortbildung Urologie
What is urology
Illnesses and disorders
Affected organs
Treatment / Diagnosis
Urology briefly explained
Stockholm3
Locations
Practices network for Urology (all)
Urology Clinic Bülach
Tumour Centre Bülach
The Zurich Andrology Centre
Contact
About us
Experts in urology
Team
Uroviva People Stories
Job vacancies
Partnerships
Media
For patients
Make an appointment
Hospitalization
Our doctors and urologists
Erweiterte Hilfe & Beratung
Broschüren & Flyer
For doctors & referrers
Downloads
Tumorboard
Therapies & Treatments
Fortbildung Urologie
What is urology
Illnesses and disorders
Affected organs
Treatment / Diagnosis
Urology briefly explained
Stockholm3
Locations
Practices network for Urology (all)
Urology Clinic Bülach
Tumour Centre Bülach
The Zurich Andrology Centre
Contact
About us
Experts in urology
Team
Uroviva People Stories
Job vacancies
Partnerships
Media
+41 44 365 10 70
Contact
Emergencies
Maennerarzt.ch
DE
EN
For doctors & referrers
Online referral form ACZ
Referral form
Sites & doctors
Choose a location
Clinic for Urology Bülach (Zurich)
Practice for Urology Horgen (See-Spital Hospital)
Practice for Urology Meilen
Practice for Urology Männedorf (Hospital)
Practice for Urology Schlieren (Limmattal Hospital)
Practice for Urology Sursee (Lucerne)
Practice for Urology Zollikerberg (Hospital)
Practice for Urology Zurich City
Practice for Urology Zurich Höngg
Urology Practice at the Private Clinic Villa im Park (Rothrist)
Zurich Andrology Centre
Choose a doctor
to the team
Patient's personal data
Title
Mr.
Ms.
First name
*
Last name
*
Date of birth
*
Email
Address / Apt. Nr.
*
Zip code / City
*
Phone
Insurance company
Type of insurance
Private
Semi-private
General
Type of insurance
Diagnosis / Issues
Your diagnosis / issues
*
Type of appointment
Please contact the patient directly
The patient will make contact
Type of appointment
Desired treatment or diagnosis
Spermogram only
Basic spermiogram
Spermogram with function tests
Preparation for Intrauterine Insemination (IUI)
Spermogram only
Other
Hypogonadism/ Hormone Screening
Erectile disfunction
Premature ejaculation
Other
Fertility
Complete andrological examination (incl. spermiogram)
Unfulfilled desire for children
Vasectomy consultation
Fertility
Further comments
Comments (attach copies of lab results etc. to the form)
Other observations, e.g. treatments not listed, further remarks, etc.
Documents (optional)
Drag files into the grey area to upload
(up to 3 documents, 3MB each)
Choose file
Documents (optional)
Referrer details
Title
Mr.
Ms.
Your title, first name, last name
*
Your email address
*
Work number
I would like to be contacted by the referred physician
Within the scope of data protection provisions, I hereby consent to my personal data being sent by e-mail to the persons responsible.
*
Send