praxis@praxis-bornheim.de
After you have filled out the infection questionnaire, you can request a callback using this form.

If you have not yet filled out the infection questionnaire, we kindly ask you to complete it first and then book the callback, as we can only call you back once the questionnaire is available to the doctor.

    1. Firstname (Mandatory)
    2. Lastname (Mandatory)
    3. Birthday (Mandatory) Please use only numbers without the dots in the format DDMMYYYY like 23081999
    4. E-Mail address (Mandatory)
    5. Callback reason (Mandatory) I am positive and need a callback.I am having cold/infect symptoms and need a callback from a sick note.
    6. Infect questionary I filled out the questionary and signed it at the end
    7. Health insurance status I am private insuredThe insurance card of the Krankenkasse is already presented this quarter (New one starts always at 1.1., 1.4., 1.7., 1.10.)A substitute certificate has been requested and will be sent to you by email or fax. (In this case, please send us the front and back of your insurance card in advance, so we can continue with our work and don't have to wait for the certificate.)I will directly upload the substitute certificate with this form.
    8. Upload substitute form from your Krankenkasse
    9. Upload front side of insurance card
    10. Upload back side of insurance card