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Registration Form new Patient

Birthday
Month
Day
Year
Gender
Man
Woman

Contact details

Multi-line address

Insurance

History

Medical data

Usage
Problems
Do you have a chronic illness?
What chronic illness runs in your family?
Are there any hereditary diseases/conditions in your family?
No
Yes, explained....
Are there any hereditary diseases/conditions in your family?
No
Yes, explained....
Are you getting a flu shot?
No
Yes, why...
Are you under the care of a specialist?
No
Yes, why...
Have you ever been involved in an accident that left you with permanent damage?
No
Yes, explained...

Lifestyle

Do you smoke?
No
Yes, how many cigars/cigarettes per day?
Do you drink alcoholic beverages?
No
Yes, how many drinks per day or per week?
Do you use drugs?
No
Yes, which one?

Agree

Ik geef de Huisartsenpraktijk Dansen Kessels toestemming om de medische gegevens bij de apotheek en huisarts op te vragen (met inachtneming van het medisch beroepsgeheim)
Ja
Nee
Ik geef de Huisartsenpraktijk Dansen Kessels toestemming om de medische gegevens bij andere zorgverleners op te vragen (met inachtneming van het medisch beroepsgeheim)
Ja
Nee
Ik geef de Huisartsenpraktijk Dansen Kessels toestemming om de medische gegevens ter beschikking te stellen aan andere zorgverleners (met inachtneming van het medisch beroepsgeheim)
Ja
Nee
Ik geef de Huisartsenpraktijk Dansen Kessels toestemming om de medische gegevens uit te wisslen met het ziekenhuis in het kader van behandelingen (met inachtneming van het medisch beroepsgeheim)
Ja
Nee
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Contact details

Registration form

Do you live in Thorn or Wessem?

You're very welcome to join us. You do need to register, though. Please fill out the form below. You can also contact us for an introductory meeting.

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Rest assured that we offer personalized care and attention. Our team is ready to support you with professional services.

Pharmacy-owning GP practice Dansen & Kessels

Schoolstraat 22, 6017 CZ THORN

Steenweg 2B, 6019 AX WESSEM

 

Chamber of Commerce number: 56234961

Email address: info@huisartsenpraktijkdansenkessels.nl

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For an appointment, please refer to this page

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