Register

Select Location*

Personal details

Initial(s)*

First name*

Surname*

Gender*

Man
Woman

Date of birth*

Postcode*

House number*

Addition

Street*

City*

Citizens Service Number (CSN)*

Do you have a CSN number?

Ja
Nee

Phone number 1*

Phone number 2

E-mail

Insurance details

I don't have a Dutch health insurance

Name health insurance*

Policy number*

Permission questions

Sms-service*

Do you give us permission to use your mobile phone number for our sms service?

Yes
No

E-mail service*

Do you give us permission to use your email address for our email service?

yes
No

Participation Landelijk Schakelpunt (National Exchange Point)*

Do you give the health center permission for making your medical information available through the LSP with other caregivers?

yes
No

I have read the brochure 'Electronic sharing of your medical data? en Only with your permission!' gelezen.

Online patient portal

Our health center has an online patient portal. Via this portal you can make appointments, request repeat prescriptions and conduct an eConsult with your doctor. Do you want to use this service? Then take the following steps: create a new account in our patient portal click within 24 hours on the confirmation link in the e-mail you receive your account details will be compared to the details already known to us. In case of uncertainties we will contact you to complete the registration after completion we will activate your account and you will be able to use our online services.

Former GP

I don't have a former GP

Name of former GP*

City of former GP*

Medical file*

Do you give us permission to obtain your medical file from your former GP?

yes
No

Other

Preferred gender of the GP*

No preference
Man
Woman

Comments

Complete registration

I agree to my registration for this health center

Hidden

Location email address

Online registration form