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Contact form for patients

Please fill out the following form to contact us. Optionally, you can name a contact person to get in touch with. Please also note our privacy policy in the privacy statement at the bottom of this page. 

Please do not forget to enter the security code (Captcha) at the end of the form.

Fields marked with * are mandatory fields.

After entering your data you have the possibility to upload files (.jpg, .gif, .doc, .zip, .pdf max. 10 MB).

Patient data

Title *
Last name *
First name *
Date of birth: *
Street *
Number *
Address appendix *
Postal Code *
Hometown *
Country *
E-mail address:
Phone
Fax
Reason for referral by your ophthalmologist: *

Second person for correspondence

Titel correspondent
Last name correspondent
First name correspondent
E-mail address correspondent
Phone correspondent
Fax correspondent
Company

The answer to your request shall be submitted to?

Title recipient *
Last name recipient *
First name recipient
Answer option *
Security notice: Responses with very sensitive information: If you request the transmission of very sensitive information, we reserve the right to send it by regular mail. Our response to you via e-mail over the Internet: Every e-mail goes in plain text through the Internet and crosses many node computers in the in the hands of other organizations and individuals. It is therefore possible, though unlikely that when communicating via the Internet, unauthorized persons can read the content the content of our mail to you (and the attachment). If you do not want anyone else to you must be sure that only you personally have access to your inbox. have access to your inbox. Our reply to you via fax: If you do not want anyone else to read the reply, you must be sure.., that only you personally have access to the fax machine that you have indicated to us. you have given us. Misdirection of a fax transmission is possible but rare.
Depending on the option selected above, please enter the contact details you would like us to use to send you our reply:
E-Mail address recipient
Phone recipient
Fax recipient

Your message

Upload (jpg/gif/zip/doc/pdf)

You have the possibility to upload files (.jpg, .gif, .doc, .zip, .pdf) with max. 10 MB. Please send larger files to kontakt.augenklinik@med.uni-tuebingen.de.
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Certificates and Associations

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