Registration Form

Registration Form Huisartsen Rustenburg

Please fill in this form completely. Thank you!

Recaptcha

M / F / X(Vereist)

Last Name(Vereist)

Initials(Vereist)

First name(Vereist)

Date of birth(Vereist)

Place of birth(Vereist)

Profession

Do you have a partner or child who is registered at Huisartsen Rustenburg?(Vereist)

Yes, my partner / child is registreted as a patient at Huisartsen Rustenburg

No, i don't have a partner / child who is registreted as a patient at Huisartsen Rustenburg

Last name partner

Date of birth partner

Contactperson in case of emergency

Name and phone numer:

Adress(Vereist)

ZIP code(Vereist)

City(Vereist)

Mobile phone nr.(Vereist)

Email(Vereist)

Insurance company(Vereist)

Insurance nr(Vereist)

BSN -no. (ID)(Vereist)

Passport/ Driver's license no(Vereist)

Name previous General Practitioner(Vereist)

Please note the following! It is very important to ask your previous General Practitioner to send your medical files to our address. If not, it is difficult to help you. It is your own responsibility that your medical file of your former G.P. is sent to us!

Adress(Vereist)

Zip code(Vereist)

City / Country(Vereist)

Phone nr.(Vereist)

Do you authorize Huisartsen Rustenburg to request your medical file?(Vereist)

Yes I do authorize Huisartsen Rustenburg

Pharmacy(Vereist)

Adress, Zipp code(Vereist)

Allergies(Vereist)

Particularities(Vereist)

Do you smoke?(Vereist)

I / We prefer to be registrated with (name GP)(Vereist)

Do you authorize Huisartsen Rustenburg to make your data available through LSP (National Exchange Point) after reading and understanding all the information on volgjezorg.nl?(Vereist)

Confirmation email

Phone

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