Registration form

(last name, if applicable)
Format: DD/MM/YYYY
*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 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.
*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.
Name and address