Form - spielzeit

Contact Form

We look forward to hearing from you.
We ask professionals and insurance companies to use the email address spielzeit@hin.ch .

* = Required field

Title*Mr.Ms.Other

First Name*

Last Name*

Street/No.*

ZIP Code*

City*

Email Address*

Phone Number*

Relationship to The Patient*

Patient's GenderMaleFemaleOther

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Age (years)

Native Language

Known diagnosis(es)
If applicable, separate multiple diagnoses with commas.

Type of Inquiry*

Your Inquiry / Message*
Max. 2,000 characters Referring Professional (if applicable)

Please upload relevant documents here
Max. 4 MB (PDF, JPG, PNG) Max. 4 MB (PDF, JPG, PNG) Max. 4 MB (PDF, JPG, PNG)

I have read the Privacy Policy and consent to the processing of my data for the purpose of establishing contact.*