Request for Care

Application Form

Complete the form below for Stockholm Care to handle your request efficiently and offer the Patient Care of your choice. Please write in English. A Customer Service Managers will review the application and will contact you within three business days to suggest how to proceed.
Note: Fields marked with * sign are mandatory.

MEDICAL INFORMATION


Medical Second Opinion
Multidisciplinary Team Opinion
Treatment

PAYMENT METHOD


PATIENT INFORMATION

Please provide patient information as it appears on the passport




Yes
No

PATIENT CONTACT INFORMATION

MAIN CONTACT INFORMATION (If that will be other person than patient)


CONSENT FOR PROCESSING OF PERSONAL DATA

By checking the “I Agree” checkbox below, I acknowledge that I have read and agreed to the enclosed Consent for processing of personal data. I certify that I am at least 18 years old and that I am the patient or have the power of attorney to represent the patient. I understand that by checking the “I agree” checkbox, I apply my electronic signature to this application and will be bound with the same force and effect as if I had signed this application on paper by hand.

I Agree

Error:

Thank you for your request!

An e-mail will arrive shortly in your inbox to acknowledge the receipt of your application. We will send an e-mail confirmation to the address you provided. Please note that some spam filters may prevent our replies from reaching you. If you do not receive your e-mail confirmation within a few hours, please check your spam filter.

If you have the time now, you may like to check out our step-by-step guide explaining the self-referral process for a Second Opinion and Medical Treatment.

 

Consent for processing of personal data

Parties

  1. Stockholm Care AB, 556253-1896 (“Stockholm Care”)
  2. The undersigned Applicant, (“Applicant”)

Stockholm Care process personal data in order to be able to coordinate and to fulfill our assignment for the medical care that Applicant have requested. The handling of the Applicant’s personal data is governed by several laws, such as the Patient Data Act, the Data Protection Regulation, the Public and Privacy Act and the Archive Act.

The Applicant has accepted that Stockholm Care processes the Applicant’s personal data, including sensitive personal data. The Applicant has accepted that his/her personal data will primarily be processed by concerned parties at Stockholm Care and its subcontractors and may be used for necessary documentation, assessment of possibilities to provide medical care, assessment of appropriate care, necessary documentation during and after care, billing, process development, obtaining statistics, possible future reconnection to patient case, to secure traceability and therewith consistent measures.

The Applicant has given Stockholm Care permission to transfer all relevant personal data to concerned authorities and/or health care centres abroad if deemed necessary due to future care or for any other significant reason.

The Applicant has given Stockholm Care permission to, at any given time and without exception, access the patient records as drawn up by Stockholm Care’s subcontractors due to the Medical Services.

The Applicant has been informed that the Applicant have the right to withdraw their consent at any time. However, note that withdrawal of their consent does not affect the legality of the treatment before the consent was revoked, no more personal data will be collected, but all data collected up to that time may be retained.

The Applicant may at any time submit, once per calendar year without charge, a written request in order to be informed about what personal data Stockholm Care holds about you, including how the personal data is processed and the right to correction of data in cases where the registered data would not be correct and in some cases to have the data deleted. The rights depend on the legal basis on which the processing of personal data rests. This means that certain rights apply only under certain conditions.

More information and contact
To request Applicant’s personal data, request shall be made in writing and sent to Stockholm Care AB, Box 6423, 113 82 Stockholm, Sweden.

For questions about Stockholm Care’s processing of personal data or Applicant´s rights under the Data Protection Regulation, you are welcome to contact us at dataskyddsombud.stockholmcare@sll.se

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