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*	111 - Všeobecná zdravotní pojišťovna ČR 201 - Vojenská zdravotní pojišťovna ČR 205 - Česká průmyslová zdravotní pojišťovna 207 - Oborová pojišťovna bank a pojišťoven 209 - Zaměstnanecká pojišťovna ŠKODA 211 - Zdravotní pojišťovna Minister. vnitra ČR 213 - Revírní bratrská pokladna, Ostrava 333 - Pojišťovna VZP, a.s. 400 - samoplátce 401 - VZP-cizinci 999 - neudáno
Contact details
Telephone *
E-mail *
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