Become a patient form

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General Practitioners MCNO

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Become a patient form

What do you want to do with this form? *Register myself as a new patientRegister someone else at my address

Do you live in our practice area? *Please check if you live in our practice area to prevent misunderstandings. You can check that hereYes

Do you prefer a practice? *No preferencePractice Quanjel, Gaal and SteeghsPractice Verbeten and SlootsPractice Suidman

On which address do you live?

Street name *0 / 30

Number *0 / 4

ZIP Code *0 / 8

Patient information

Gender (as stated in your passport) *

First name *

Initials *

Middle name

Last name *

BSN number0 / 10

Date of birth *

Day

Month

Year

E-mail address *

Confirm your email address *

Phone number (mobile) *0 / 10

Phone number (home)0 / 10

Your previous GP

Name of your previous GP

Place of your previous GP

PermissionI gave permission to my previous GP to obtain my medical records

Reason of your application

Reason *I moved to Nijmegen Oost and needed a new GPI came to study in NijmegenI'm adding a child or other house memberI'm not satisfied with my previous GP and looking for another

Did you receive any of the following care?

I received the following careIf you check one of the options below, we will invite you for an appointment with our practice nurse(Practice nurse) for asthma(Practice nurse) for COPD(Practice nurse) for cardiac disease(Practice nurse) for CVA(Practice nurse) for psychological complaints

Allergies

Do you have any known allergies *YesNo

Allergies

Pharmacy

Which pharmacy do you want? *As standard we set Pharmacy Nijmegen OostPharmacy Nijmegen OostOther

Pharmacy text

Sharing your medical records

Sharing medical record *Do you give permission to share your medical record with the out-of-hours medical care if you need there help?YesNo

Other remarks

Other remarksIf you want you can fill in other remarks

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GP MCNO
Berg en Dalseweg 63
6522 BB Nijmegen
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