REGISTRATION FORM

Register at our practice

Our practice is open to new patients. We warmly welcome you. You can register using our registration form.

Register as a patient at our GP practice

We’re pleased that you would like to register with our general practice. For new registrations, we follow a postal code policy. This means that new patients must live within a certain distance from our practice. If you live in a postal code area outside our service area we cannot accept your registration.

We use the information from the form to process your registration. If you have the Dutch nationality, we ask you for your citizen service number (BSN). We do this according to the rules of the Dutch Citizen Service Number in Health Care Act (Wbsn-z), so that we can confirm your identity as a patient.

Your personal details

Salutation *
Marital state

Your situation

May we share your medical information with the pharmacy and the Emergency Medical Centre? *

Family reunification

Have you (recently) started living with someone who is already registered in our practice? *
Relation to the person *

Your address

Your contact details

Who can we contact in case of an emergency? *

Insurance and identification

Identification document *

Medical data

Do you smoke? *
Do you have any of these chronic diseases? *
Are you allergic to any type of food or medications?
Have you had any surgeries? *
Do you have any other medical conditions? *

Overview of your medication

Do you use prescribed medication? If so, please let us know which medication you are taking. You may skip this if you do not use any medication.

Medicine 1

Medicine 2

Medicine 3

Medicine 4

Medicine 5

Medicine 6

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