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Initials*
First Name*
Last Name*
Gender*MaleFemaleOther
Date of birth *
Street and house number*
Postal code*
City*
Phone number*
Mobile phone number
Email address*
Marital status (adults)*marrieddivorcedliving togetherregistered partnershipsinglewidowednot applicable

Emergency contact *
Phone number Emergency contact

Name of health insurance policy*
Policy number*
BSN number (citizen service number)*
Proof of identity*—Kies een optie—PassportDriver's licenseID cardForeign national document
Number proof of identity*
Your (new) pharmacy*Apotheek Schenkelapotheek de Rozenburchtapotheek Capelle centrumapotheek Spoorlaanapotheek ’s-Gravelandapotheek Schollevaarapotheek het Lage Landapotheek OostgaardeOther
Your previous general practitioner (name and city)*
Do you live with your partner and is your partner already a patient at this practice? Please provide your partner's name and date of birth below
Brief medical history (allergy, illness, surgery)*
List of medications you are taking*
Do you receive an annual invitation for the influenza vaccination based on medical indication? *YesNo
If so, do you actually want to get the influenza vaccination?*YesNo

Would you like to access the online patient portal via MijnGezondheid.net? This allows you to view your medical records, request repeat prescriptions and e-consultations, and schedule appointments online*YesNo
Do you give permission for your medical data to be made available through the Landelijk Schakel Punt (LSP)? Through the LSP, other healthcare providers, such as the GP out-of-hours clinic and pharmacy, can request medical information from your GP's file*YesNo

Do you give permission to request your medical records from your previous GP?*janee

Signature*

I have completed the registration form truthfully and agree to the processing of my personal data.

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