Register with the General practitioner

Do you live in zip code area 3524? Then you can register as a patient.

Would you like to register more than one person? If so, please fill out the form separately for each person.

For children, please note:

For children ages 0-11: parent/guardian must sign.
For children aged 12-16: parent/guardian and child must sign.
For children aged 16-18: child completes the form on his/her own and provides his/her own signature.

Personal data:

Last name:
Initials:
First name:
Male / female:

Birth name:

Date of birth:

Marital status:

Identification:

BSN (Citizen Service Number)
Legal identity document

Number identity document

Contact details:

Street

Number

Zip code

City
Telephone

Email address

Emergency contact:

Name

Telephone

Insurance:

Name insurer?

UZOVI code insurer

Contact number

Pharmacy:

At which pharmacy will you register?
Lunetten apotheekOther

Other pharmacy

Previous general practitioner:

Name GP
City
Telephone

Do you give permission to request your medical file from your previous general practitioner?

yesno

Other:

When do you want to be registered?

Do you give permission to the general practitioner to make your data available for consultation by other healthcare providers

yesno

Can we send you an annual email with a number of questions about our practice and services?

yesno