Registration form

To register with us, you must be resident in Voorschoten.

To register in the practice, you can fill out the form below.
A seperate registration form is required for each family member!

If you would like to schedule an introductory meeting, you can contact the medical assistant on 071-5612118.

The intention is that you unsubscribe yourself from your previous GP and ask him to provide us with your medical file.

Thank you in advance!

Registration form English

Gender(Vereist)

Surname(Vereist)

Initials(Vereist)

First name

Date of birth(Vereist)

Address(Vereist)

Streetname + house number City Zip code

Telephone number

Mobile phone number(Vereist)

Email address(Vereist)

BurgerServiceNummer(Vereist)

Insurance company(Vereist)

Insurance number(Vereist)

New pharmacy(Vereist)

Previous GP(Vereist)

City previous GP(Vereist)

Important subjects for GP

Picture of identity card

This may be your passport, identity card or drivers license

Max. bestandsgrootte: 2 MB.

Would you like to have access to your medical file via MijnGezondheid.net?(Vereist)

I give permission to request my medical file from my previous GP/care provider(Vereist)

I give permission to exchange my medical data with other healthcare providers (www.volgjezorg.nl/en)(Vereist)

Recaptcha

Comments

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