Registration form

"*" geeft vereiste velden aan

Personal information

Surname and initials*

Surname*

Gender*

Woman

Man

Date of birth*

Place 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 in Groningen*

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 Huisartsenpraktijk De Oosterpoort*

Yes

Registration form

Personal information

Address details

Healthservice information

Registration

Openingstijden

Contact

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