Patient Registration form

Dear sir/madam,

Welcome to Huisartsenpraktijk Bloemendal. You want to register as a new patient. In order to provide the best possible service, we would like to ask you to cooperate in providing your (medical) information.

The registration form contains a questionnaire, which will gain insight into your (medical) data. We ask you to complete 1 questionnaire per person. Persons of 16 years and older must complete a registration form themselves (regarding giving permission for sharing medical data). This information will be treated with care and confidentiality.

We ask you to fill in this questionnaire carefully. We also request that you ask your previous GP to send us your medical information.

We thank you for your cooperation!

Please note:

• You can only register at our practice if you live in Barneveld.
• This is not a registration at the pharmacy.
• You will be registered in doctor Murphy’s practice.
• Are you moving in with someone who is already registered at our practice (family reunification)? Then you will be registered at the same GP as you family member/partner.
• Would you rather fill in a paper version of the questionnaire? You can pick this up at the desk at the practice.