Registration form

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Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.

Last name*

Maiden name

Initials

First name*

Date of birth*

Gender*

Male
Female

Street*

Number*

Postal code*

City*

Phone number*

E-mailadress*

enter e-mailadress confirm e-mailadress

Living situation*

Single
Family
Living with partner
Student home

If your partner is already registered in our practice, please enter name and date of birth of your partner

Birthplace and country*

BurgerServiceNumber (on passport/driver’s license)*

Form of identity*

Passport/ID card/driver’s license

Number on identity card*

Passport number/number ID card/number driver’s license

Insurance company*

Insurance number*

Name and place last General Practitioner (if situated in The Netherlands)*

New Pharmacy*

Which language(s) do you speak?*

Proffession*

Are you currently using medication? If so, please fill out name, dosage and usage*

Do you have a medication allergy? If so, what medication? What physical reaction occurred when you took this medication?*

Did you ever have surgery? If so, what type of surgery and when?*

Do you have any diseases? Which one(s)? Since when?*

Have you ever been seriously ill in the past? What disease? When?*

Are there any diseases that run in the family? If so, which family member and at what age?*

Think about cardio vascular disease and high blood pressure, diabetes, hay fever or asthma, thyroid disease, cancer (what kind of cancer?), kidney disease, epilepsy

Do you smoke, drink alcohol or use drugs? If so, what kind and how many?*

Do you play any sports or exercise? If so, what and how often?*

Would you like to use the patient portal MGN (MijnGezondheid.net)?*

yes
No

You can use this to make appointments online, request an e-consulation and repeat prescriptions. You do need to have DigiD to be able to log in.

Do you give permission to request and have your medical file sent from your previous general practitioner to us?*

Yes I give permission to request my medical file at my previous general practitioner
No

Only necessary if your previous general practitioner is in The Netherlands

Do you give permission to exchange information with other caregivers, if it concerns your treatment?*

I agree with my general practitioner informing/exchanging information with other caregivers, if it concerns my treatment
No

Do you have any other comments?

Permission to process personal data*

When sending this form I give permission that this data may be used for processing the patient’s registration. Your data will not be used for other purposes and will not be provided to third parties. Your data can be deleted again at any time. For complete information about the processing of your data see our privacy statement

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new patients registration form english

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