Inschrijfformulier

Registration Form

GENERAL PRACTICE BANDKERAMIEK

We would like to welcome you to our general practice!

Please complete the registration form below for us. We will then contact you to make an appointment.

Aelserhof 45
6181 LB Elsloo

Mw. M.A. Bremers

Mw. S.H.C.M. Smeets

Last name

Initials

Name

Gender

Date of birth

Birthplace

Country of birth

BSN

Marital status

Address

Postal code / Residence

Fixed phone number

Mobile phone number

E-mail address

Name contactperson

Phone number contactperson

Relation contactperson

Education

Work

Living situation

Family composition

Pharmacy of registration

Name of previous GP

Place of residence of previous GP

Reason of depature

Major illnesses or events

Do certain diseases run in your family?

I give permission to make my data available for consulting by other healthcare profesionals via the LSP.

agree

not agreed

I agree that my medical data that has been made unrecognizable will be shared with Maastricht University ( RNFM).

agree

not agreed

I give permission to request my medical file from my previous GP.

agree

not agreed

I give permission to create an account for the patient portal. I have my own email address and mobile number.

agree

not agreed

Bedankt voor uw inschrijving.

We nemen zo snel mogelijk contact met u op om een afspraak in te plannen.

Registration Form

GENERAL PRACTICE BANDKERAMIEK

INSCHRIJFFORMULIER

Huisartsenpraktijk Bandkeramiek Elsloo

046 – 437 16 60 (toets 1 voor spoed)bandkeramiek@ezorg.nlAelserhof 456181 LB, Elsloo Spoed buiten kantooruren: 046-400 99 25 toets 1 www.spoedpost-westelijke-mijnstreek.nl

046 – 437 16 60 (toets 1 voor spoed)
bandkeramiek@ezorg.nl
Aelserhof 45
6181 LB, Elsloo

Spoed buiten kantooruren:

046-400 99 25 toets 1

www.spoedpost-westelijke-mijnstreek.nl