English: patient registration

Our general practice is open to new patients. At present, the following doctors take on new patients:

Mrs. J.M.T. Oltheten
Mr. A.B.J. Scholtes
Mrs. C.W. Vliet Vlieland

Should you have a preference for one of the doctors, this will be taken into consideration, especially if a member of your family or your partner is already a patient.

You can register by filling in the form below. Please remember to sign the form and hand it in at the reception.

Your health insurance will only accept your registration when you have signed the form in agreement.

Do you also want to fill in the signing-out form? Then we will take care of transfering your medical files and signing you out with your previous G.P.

Should you wish to meet your new doctor, you can make an appointment by phoning: 071-361 93 00 (choice 1, choice 2) or calling in at the reception.

Mention when making an appointment that it is for making acquaintance with the new doctor. We will then reserve extra time for the appointment.

Personal information

Surname
Maiden name
Initials
Name used
Sex	Male Female
Date of birth	(dd-mm-yyyy)
Address
Zipcode
City
Telephone number home	Secret number
Telephone number mobile
Burgerservicenummer/ sofinummer
New general practitioner	Mrs. J.M.T. Oltheten Mr. A.B.J. Scholtes Mrs. C.W. Vliet Vlieland At present, the following general practitioners take on new patients: Mrs. J.M.T. Oltheten Mr. A.B.J. Scholtes Mrs. C.W. Vliet Vlieland If you prefer a different general practitioner we will take that into account.
Date of registration	(dd-mm-yyyy)

Is there already a family member registered in our practice?
Yes No

Name
Date of birth	(dd-mm-yyyy)
Name general practitioner

Which pharmacy do you choose?	Duinrand Apotheek (Noordwijk-Binnen)
	Apotheek aan Zee (Noordwijk aan Zee)

Insurance company

Main payer
Name insurance company
Registration number
Last general practitioner
Address
Postal code
City

Have you ever been admitted to a hospital?	Yes No When For what reason
Are you being treated by a specialist?	Yes No Please specify the treatment Name specialist Specialty
Do you use any medication?	Yes No What medicine?
Are you allergic to a medicine or something else?	Yes No Which substance?

What is your profession?
Do you have any children?

Because of our prevention quality care, could you fill out the following questions.

Are there in the famlily one of the following diseases:

Are there any other important things we have to know?

Gezondheidscentrum Wantveld will take care of writing you out and retrieval of your medical file from your previous general practitioner.

Have you ever had a pap smear test done?	Yes No Year Normal Abnormal
Have you ever had an influenza vaccination?	Yes No Medical reason Yes No
Have you ever had examination for breastcancer?	Yes No Year
Have you ever had a bloodtest for cholesterol?	Yes No Result
Have you ever had your bloodpressure measured?	Yes No Result
Do you smoke?	Yes No How many packs per day?
Do you use alcohol?	Yes No How much?
Do you use drugs?	Yes No Which drugs?
Have you had your spleen removed?	Yes No

Heart disease	Yes No Who? Which age?
Diabetes	Yes No Who? Which age?
Glaucoma	Yes No Who?
Allergy	Yes No Who?
Lung diseases	Yes No Who?
Cancer (lung, breast etc.)	Yes No Who?
Any other diseases in the family?