Registration form Note: you will have to fill in a form per person. Registration form English form to registrate yourself as a patient here. Only for inhabitants of Nuenen with a GP (General Practitioner) outside of Nuenen. 1Personal details2Adress3Contact information4Health care insurance5Previous GP6Medical information7Sharing medical information8Important last notes BSNYour citizen service number. Only fill in when you have one. Type of identication document(Vereist) Passport ID-card Drivers license Residence permit Document number(Vereist) Date of birth(Vereist)dd-mm-yyyy DD dash MM dash JJJJ Sex (gender)(Vereist) Male Female Nationality(Vereist) Name(Vereist) First name Surname (family name) Surname (before marriage)Your maiden name, only fill this section in if you are married and changed your surname City/Town(Vereist)As a practice located in Nuenen please keep in mind we serve patients living in Nuenen only. Streetname and house number(Vereist) Postcode(Vereist) Telephone number(Vereist)Preferably a 06-number or your mobile phone number.E-mailadress(Vereist) Health care insurance(Vereist)The name of your health insurance company Policy number(Vereist)This is your personal number for your insurance Did you have a GP in the Netherlands before?(Vereist) Yes No GP = General practitioner/ family doctorIn what city was this GP located?(Vereist) What is the name of this GP/ GP's practice?(Vereist) Choose a pharmacy(Vereist)Please make a choice; we work together with the 2 pharmacies (in dutch Apotheken) in Nuenen. Pharmacy Nuenen is located in the same healthcare centre as our practice. So it is really easy to pick up your prescriptions. Pharmacy aan den Berg is located in the city centre of Nuenen. Apotheek Nuenen Apotheek aan den Berg Did you get the flu (influenza) vaccination last year?(Vereist) Yes No What is the reason for this?(Vereist)You stated that you have received a flu or influenza last year. Can you explain the reason (medical or at your own request)?Important medical information that you want to submit here?Allergies or medication intolerances or we need to be aware of?Are you moving in with someone who's a patient at our practice?(Vereist) Yes No Name and date of birth of the patient Important information (PLEASE READ)Did you know you have to give permission to other healthcare providers to access your medical file? Please note that they can only see the most important information through the National Exchange Point. This is especially important if there would be an emergency outside of our working hours for which you to be evaluated in the hospital. That way your acting healthcare provider can see the necessary information he or she needs for your treatment, but his is only possible if you give your permission. MORE information needed before you maken this choice? Visit: www.volgjezorg.nl/en/lsp Do you give permission to share some information from your medical file with other healthcare professionals?(Vereist) Yes No Do you want to be able to see your own medical file at our digital portal MGn?(Vereist)MGn; www.mijngezondheid.net is a website in which you can see your medical history, renew precreptions or ask questions to your healthcare provider. You need to make an account at the website (you need your DigiD account for this). Yes No Do not forgetPlease notify your previous GP (if located in the Netherlands) of your transfer. LastlyAfter you receive a conformation e-mail from us stating that you are a patient with us you have to identify yourself next time at our frontdesk so we can confirm your identity. For this you can bring your passport, ID card, driver's license or a valid dutch permit document. Thank you.CAPTCHACommentsDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.
