Dutch

Registration Form

We welcome new patients to our practice De Hogewoerd.

Registration Procedure:

We kindly ask you to fill out the form as completely as possible.
For each family member, the form must be filled out separately.
Please bring a valid ID when visiting the general practitioner's practice for the first time so we can verify your identity.
You can also download a paper version of our form from our website and submit it to the practice daily between 09:00-12:00.
Don't forget to inform your old general practitioner about your move.
You must give permission to your old general practitioner to transfer your medical records.

Patient information (1/5)

Maiden name:

Last name (in case of marriage)*:

Initials*:

First names*:

Nickname (also known as)*:

Date of birth*:

Gender (passport)*:

Address and contact information (2/5)

Street + No.*:

Postal code*:

City*:

Phone*:

Email*:

Personal details (3/5)

Marital status*:

BSN number*:

Health insurance company*:

Insurance number*:

Previous general practitioner*:

City previous general practitioner*:

Preferred pharmacy*:

Did you receive a flu shot call from the previous general practitioner?*:

Have you been vaccinated according to the national vaccination program?*:

How did you find us?*:

Permissions (4/5)

Do you give permission for processing your personal data in the LSP*:

The GP, the GP emergency centre and pharmacy will be able to share relevant medical information when you give permission to use de landelijk schakelpunt

More information...

The digital assistant is the method we use in our practice to allow the patient to contact the general practitioner. Do you give permission for the use of your data to register you with our digital assistant Talk to the Doctor? *:

Your data will not be used for other purposes and will not be provided to third parties. Your data can be deleted at any time. Permission for this method is essential to be able to register you in our practice.

More information...

Permission to process personal data

Full name*:

Date and place*:

I hereby agree with a checkbox instead of signing

Request for dossier (5/5)

Permission to process personal data

By signing this form, I give permission for these data to be used for the processing of the patient registration. Your data will not be used for other purposes and will not be provided to third parties. Your data can be deleted at any time.

More information...

Full name*:

Date and place*:

I hereby agree with a checkbox instead of signing

Submitting the form may take a moment.