Registration form

You can only register in our practice if you live in RijswijkBuiten

Initials *

Nickname *

Last name *

Gender *

Last name partner/spouse

Desired nickname

(last name, if applicable)

Birth date *

Format: DD/MM/YYYY

Place of birth

Address *

Voornaam

Achternaam

Postal code & City *

Voornaam

Achternaam

Telephone number *

Phone number contact person

E-mail *

Social security number (BSN) *

Insurance company *

Insurance certificate number *

Type of identity document *

Identity document number *

LSP approval

*LSP Permission for the exchange of medical data Do you give permission to the General practice RijswijkBuiten to make data available for other healthcare providers, as described on the website www.volgjezorg.nl? If you want to give permission, please check LSP “yes” or if you don’t check “no”. For children till the age of 12, parents/guardians gives permission For children between age of 12 and 16, both parents/guardians and child gives permission Children that are 16 years or older are legally ‘grown up’ for medical decisions so they give permission or not, all by themselves.

Do you have a ZZP indication or do you live in a care institution? *

*If yes, in principle, we do not accept new patients from a healthcare institution. If you have a ZZP indication, call the assistant for options.

Profession

Previous family doctor

Name and address

Do you have any medical problems at the moment? (Diabetes, high bloodpressure, etc)

Which important medical issues have occured in the past? (operations or hospitalization)

Are you using any medication ? Please indicate name and dose of any medication you use, including painkillers and birthcontrol etc.

Do you have any allergies for (prescription) drugs, or any other allergies?

Are there any diseases known within your family? E.g. diabetes

Do you have an idication for the flu vaccine

In case of 16 years of age or younger, and the parents are separated: How has custody been arranged?

Contact details of the other parent or caretaker

Do you have any topics to share which are important for your family doctor, like important life events (positive or negative)?

You will not receive a confirmation of you registration. If you want to know if you are registered please contact the assistant after one week.

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