Registration Form copy – Amsterdam Huisartsen Bos en Lommer Dokters

Currently our practice does not accept new patients.

Exceptions are made for family expansion and partner of patients living at the same address.

Please state this clearly on the registration form.

Our practice is currently accepting new patients If you live in post code area 1055

Registration Form

Personal data

First Name *
Initials
Last name *
Maiden name
Date of birth *
Gender *
BSN Number *
Date of subscription *

Address info

Care 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's
Address 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 info

Health insurance *
Health insurance number *

Previous GP/pharmacy

Name (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 file

I hereby grant permission to view my medical data. *
I 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 *

Verification

Enter two numbers with no spaces (Example: 12) *(Example: 12)
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Currently our practice does not accept new patients.