Registration form

Huisartsenpraktijk Groningen

"*" geeft vereiste velden aan

Personal information

Surname and initials*

Surname*

Gender*

Woman

Man

Date of birth*

Telefoon*

E-mailaddress*

Profession / Education

Citizen service number*

Address details

Address*

Street + number

City

Postal code

Healthservice information

Health insurance company

Health insurance number

Pharmacy

Country of origin

Previous general practitioner

Emergency contact

Name + phonenumber

Registration

Registration date

Registered from this date until further notice.

You give permission to send a copy of this form to your last general practitioner, so he/she can be unsubscribed from the previous patientregister. This will be done at the date mentioned above.*

Yes

Do you give us permission to make your patient file accessible to other doctors and pharmacists?*

Yes

Undersigned requests his/her previous practitioner to send the medical data to R.E. Filius*

Yes

Registration form

Huisartsenpraktijk Groningen

Personal information

Address details

Healthservice information

Registration

Openingstijden

Contact

Direct naar

Service

Tijdelijke huisvesting