Registration Form English – Amsterdam Huisartsen Bos en Lommer Dokters

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?

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 *