Registration FormPersonal dataFirst Name *Initials Last name *Maiden name Date of birth *Gender *ManWomanDiffrentBSN Number *Date of subscription *Address infoCare area You CAN register if you already live or will shortly move to postcode area: 1055, 1014 and 1056-between our practice and Jan van Galenstraat. You can NOT register if you already are registered with a GP-familydoctorspractice in one of these postcode area'sAddress and house number *Post code *place *Telephone number *Email *Does a family member/partner live at the same address who is registered with our clinic? If so what is the date of birth? Insurance infoHealth insurance *Health insurance number *Previous GP/pharmacyName (GP) *Address (GP) Place Telephone numbe (GP) New pharmacy *Old pharmacy *Your attention: please inform your previous GP that you have registered with us and give the GP permission to send us your fileI hereby grant permission to view my medical data. *I permitI don't permitI hereby give permission to be registered as a patient of Huisartsenpraktijk Bos en Lommer Dokters (general practitioners) and to have my medical data transferred from my previous doctor *I permitI don''t permit VerificationEnter two numbers with no spaces (Example: 12) *(Example: 12)Deze ruimte is voor spam beveiliging - <strong>a.u.b. blanko laten</strong>:
