ESYSTA - Arzt

Personal data

Establishment number (BSNR):

Please complete if you are registered with an Association of Statutory Health Insurance Physicians.

Medical chamber: *

Unified CME number (EFN): *

Unified CME number

Salutation: *

Title:

alternative title:

Given name: *

Surname: *

Specialization: *

Specialization alternative: *

Range of activity: *

Hospital

Practice

Hospital details

Name of institution: *

Department:

Practice details

Name of doctor's practice: *

In case of networked practices (ambulatory health care center, etc.) please specify the name of the institution.

Specialization of Doctor's office: *

E.g. diabetology or cardiology

Street / Number: *

Postcode: *

City: *

Country: *

Phone: *

Fax:

Details of your user account (profile)

Please fill in your e-mail address and a password of your choice.

E-mail: *

Repeat e-mail: *

Password: *

Min. 10 characters, no more than 2 identical characters in a row (e.g. '... 111 ...' is not allowed) and at least 3 of the following 4 conditions: at least 1 capital letter, at least 1 lowercase letter, at least 1 digit, at least 1 special character
Do not give your password to anyone else.

Repeat password: *

Which blood glucose unit do you use?

Unit*

mg/dl

mmol/l

Which unit do you use for carbohydrates?

Unit for carbohydrates*

BU

CHU

g

Would you like to activate the reception of messages from your patients within the ESYSTA Portal?

Enable messages:

I would like to use the messaging function of the ESYSTA Portal.

Mandatory consent *

I agree to the terms and the data protection declaration and I consent to my personal data being collected, processed and stored by ESYSTA for the intended use. This is necessary for the use of ESYSTA, billing and verification.

Optional consent

I consent to Emperra GmbH informing me, for example, to take part in studies or surveys.