Online Inschrijfformulier

Health center

Select your health center below or select a center on the map

Personal details

Initial(s)

First name

Surname

Gender

Man Woman

Date of birth

Postcode

House number

Addition

Street

City

Citizens Service Number (CSN)

Phone number 1

Phone number 2

E-mail

Insurance details

I don't have a Dutch health insurance

Name health insurance

Policy number

Permission questions

Do you give us permission to use your mobile phone number for our sms service?

Yes No

Do you give us permission to use your email address for our email service?

Yes No

Participation Landelijk Schakelpunt (National Exchange Point)

Do you give the health center permission for making your medical information available through the LSP with other caregivers?

Yes No

I have read the brochure 'Electronic sharing of your medical data? Only with your permission!'.

Former GP

I don't have a former GP

Name of former GP

City of former GP

Do you give us permission to obtain your medical file from your former GP?

Yes No

Other

No preference Man Woman

Comments

Complete registration

We kindly request to print the completed form. You can hand in the form at the counter of the health center. You do not have to make an appointment for this.

You can find the opening times on the website of the health center. Please note that it is very busy in our health centers before 10 a.m. You might have to wait a while until we can help you.

Please don’t forget to bring your insurance certificate and proof of identity to the health center. After we have received the registration form and have seen your proof of identity and insurance, you are registered.

Online registration form

Personal details

Insurance details

Permission questions

Former GP

Other

Complete registration