Registration-form new patiënts Huisartsenpraktijk Pennings Prins Frederik Hendrikstraat 1a 3051 EM Rotterdam 010 – 4225146 huisartsenpraktijk.pennings@gmail.com
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Explanation |
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1. |
Gender |
[ ] Male [ ] Female |
Indicate what is applicable |
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2. |
Date of birth (year-month-day) |
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DOB: YYYY-MM-DD |
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3. |
Marital status |
[ ] Married [ ] Single [ ] Living together [ ] Wid. |
Indicate what is applicable |
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4. |
Surname |
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Your surname |
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5. |
Surname wife/husband |
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If applicable |
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6. |
Initial(s) |
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Your initials |
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7. |
First name |
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Your First name |
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8. |
Address (Street/number) |
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Your address |
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9. |
Area code/City |
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Your area code: ####AA / Your city |
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11. |
Landline/Mobile |
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Your landline & mobile phone number |
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13. |
E-mail address |
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Your e-mail address |
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14. |
Social Security number (BSN) |
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Your Dutch social security number |
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15. |
Health Insurance company |
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Your health Insurance company |
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16. |
Health Insurance ID-number |
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Health Insurance ID-number |
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17. |
Pharmacy *) |
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Your pharmacy |
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18. |
Previous general practitioner
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Your previous GP (name/address, if in the Netherlands) |
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19. |
Yes [ ] No [ ] |
Consent for requesting my medical record from my former GP (if in the Netherlands) |
Consent for requesting your medical record from your former GP |
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20. |
Yes [ ] No [ ] |
Consent for connecting my medical digital record to the LSP (an ‘Electronic Patient Document’) |
Consent for connecting your digital medical record to the LSP |
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21. |
Date/Signature |
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Registration date / signature |
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23. |
Remarks/Allergies /etc |
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*) Our practice has an on-line connection with a number of pharmacies
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Registration Form scanned |
COV |
ION |
LSP |
MEDICOM
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Identification Document (+number) |
Medical file requested |
Medical file imported |
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