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Registration of ordering system user

To register successfully, please fill in the registration form.
Items marked with a star (*) are required! If they are not filled in, you will not be successfully registered!

Information for logging in	Patient info
Log-in name *		User name is of length min 5, can contain letters without diacritic, digits and a characters @ . _ -
Password *		Password is of length min 8, must have 1 uppercase letter, 1 lowercase letter and a 1 digit.
Confirm password *

Personal data
Title
Name *
Surname *
Title after name
Address *
Town/City *
Postal code *
Country *
Insurance no. *		Patient insurance number of length 9 or 10 digit, enter the number without formating slash.
Insurance company code*

Contact details
Telephone *
E-mail *

Spam protection:
Enter code on image


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** Important notice:

After successful registration, your account is set up, but not activated! Information on activation (what it brings you and how you can activate it) can be read this link

Registration of ordering system user

Information for logging in

Personal data

Contact details