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Registration form General Practitioner – Gezond op Zuid Katendrecht

Would you like to register with the Gezondheidscentrum Katendrecht general practice? This is possible if you live in the postal code area 3072.

Please note that the GP must be able to be with you within 15 minutes in case of an emergency. Upon registration, it will be checked whether this is actually possible on the basis of your home address.

Your registration can only be finalized when we have all the necessary information, you have been deregistered from your old GP and your medical file has been transferred. From that moment you can make an appointment with us.

_{Please keep in mind that at our location the working language is mainly Dutch and English.}_{If you prefer to be helped in another language, please inquire about the possibilities}

Registration form General Practitioners Gezond op Zuid - Katendrecht

Personal data
Sex*
- Man
- Woman
- Otherwise
Initial(s)*
First name*
Last name*
Date of birth*
Citizen service number*
Nationality*
Contact details
Street name*
House number*
Postal code*
Place*
Telephone number*
E-mail address*
Other contact details
Do you have a guardian, carer, informal carer or it this a registration for a minor?*
- No
- I have a guardian
- I have a carer
- I have an informal carer
- This registration is for a minor
We would like to receive his or her contact details.
What is your relationship to this person? For example: Partner/Parent/Child*.
Details of a previous GP
Name of previous GP*
Phone number previous GP*
Insurance data
Health insurer*
Health insurance number*
Other information
Are you being treated by a specialist?*
- Yes
- No
With which specialist are you being treated?* (hospital, department, name of specialist)
Do you use medication?*
- Yes
- No
What medication are you taking? (name and dosage)
Have you had surgeries?*
- Yes
- No
What operations have you had? (for what and when)
Do you have allergies?*
- Yes
- No
What allergies do you have?
Do you have one or more of the following conditions?
- No
- Diabetes Mellitus (Type 1 or 2)
- High cholesterol
- Heart and vascular disease
- Asthma
- High blood pressure
- COPD
Do you smoke or have you ever smoked?*
Permissions
*
- Yes, I give permission to request my file. Your GP uses the online patient portal MijnGezondheid.net . This is a secure website and app where you can view your medical data, request repeat prescriptions and maintain contact with your GP online.
MgN*
- Yes, I want to use MijnGezondheid.net. Your GP can share important information about your health with other healthcare providers (e.g. the GP, pharmacy, hospital, etc.). But they are only allowed to view your medical data if this is necessary for your treatment, and only if you agree. For more information, see www.volgjezorg.nl
- No, I do not want to use MijnGezondheids.net.
More information about MGn read here.
*
- Yes, I give permission for the exchange of my data
More information about exchange of your medical data read here.
Permission*
- I agree with the privacy of statement of Zonboog: www.zonboog.nl/privacy-statement/

Ontwikkeld door: Yardzorgsites.nl