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Register with the General practitioner

Here you can register as a patient with the family doctor.

Registration consists of 3 parts:

personal data
medical data
permission to share information with other health care providers

Note: Complete these forms separately for each family member.

Personal data:

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

Birth name:

Date of birth:

Marital status:

Identification:

BSN (Citizen Service Number)

Contact details:

Street

Number

Zip code

Town
Telephone

Email address

Emergency contact:

Name

Telephone

Insurance:

Name insurer?

UZOVI code insurer

Contact number

Pharmacy:

At which pharmacy will you register?
De VogelvlinderFleirapotheek TerwijdeFleirapotheek ParkwijkFleirapotheek Leidsche Rijn CentrumFleirapotheek VleuterwijdeFleirapotheek VeldhuizenBenu apotheek De MeernOther

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?

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

yesno

Additional medical information:

height (cm):
weight (kg):

Are you familiar with...

AstmaCOPDDiabetes, type 1 of 2Elevated cholestorolSpleen removedEpilepsyHigh blood pressureHeart and/or vascular diseasesCancerKidney diseaseMental illness

what heart/vascular disease is involved?

what kidney disease is involved?

what type of cancer is involved?

what mental illness is involved?

Are you allergic to...

Hay feverFoodAntibiotics or other medicationsOther (think band-aids, iodine, etc.)

What foods are you allergic to?

What medications are you allergic to?

other allergies?

Do you use stimulants?

AlcoholDrugsSmokeUsed to smoke

how many glasses of alcohol a day?

what drugs are you using?

how many cigarettes a day?
Since when do you smoke (year)?

you smoked from... (year)? till
how many cigarettes a day?

Familial disorders

brother / sister / father / mother
DiabetesCancerElevated cholestorolThrombosisDied before age 60 of cardiovascular disease

Are you taking medication?

Yes

What medication are you taking (name, strength, usage)?

Remarks?

Please provide additional information here...

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