Application

First Name

Last name

Birthday

Please provide your date of birth in the following order: Day, Month, Year, for example: 15th June 1944.

Address

Town

Postal code

Country

Nationality

Place of birth and country

Phone numbers with country code

E-Mail

Confirm E-Mail

When do you plan to come to Switzerland for the Voluntary Assisted Dying (VAD)?

Please provide the date in the following order: Day, Month, Year, for example: 15th June 1944.

Which languages can you communicate in?

How can we contact you?

E-Mail

Phone

by Post

Or a preferred app

Video call via which platform or Video call using which channel

Your contact details