Een AZALEA praktijk TNO keurmerk
Medisch Centrum Loudon, Loudonstraat 118, 2593 WB s-‘Gravenhage
REGISTRATION FORM
o Practitioner Feenstra/Geenen
070-383 53 53 Medicom: FF
070-322 21 20 Medicom: YS
070-385 44 42 Medicom: HH
070-315 4145 Medicom: MK
o Practitioner van Aken, Beeftink, Dirkzwager
o Practitioner Hulsebosch
o Practioner Makkink
Medical centre Loudon, Loudonstraat 118, 2593 WB ’s-Gravenhage
 Please bring a copy of your identification with you.
Surname:……………………………………………………………………………………..
First name:………………………………………. Initials:…………………………............
Date of birth :…………………………………………………..
0 Male
0 Female
Place of birth:…………………………………………………………………………….
Marital status:
0 Married
Children:
0 Yes
Address:
0 Single
number:……
0 Divorced
0 Widow(er)
0 No
Street and number:…………………………………………………………
Postal code and city:……………………………………………………….
Telephone numbers: Home :...................................................
Work :…….............................................
Mobile :..................................................
Email address………………………………….................................................................
Profession:……………………….....................................................................................
Pharmacy: .....................................................................................................................
Previous G.P:.....……………………………………………City:.......................................
*Insurance……………………….......... Cardnumber:………………………..
BSN number:
City:
Date:
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Signature:
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ONLY COMPLETELY FILLED OUT FORMS WILL BE ACCEPTED PAG.1 T/ M 3
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HEALTH AND DISEASES
1. Have you ever suffered from:
- Diabetes
- Lung diseases
- High blood pressure
- Coronary diseases
- Depression or fears
- Liver or intestinal diseases
- Eating disorders
- Sustained pain in the joints
- Venereal diseases
- Thyroid diseases
- Epilepsy
0
0
0
0
0
0
0
0
0
0
0
2. Are you presently being treated by a specialist:
- No
0
- Yes
0
specialism: a)…………………….. .................
b)……………………...................
3. Are you presently on medication:
- No 0
- Yes 0 Medication
Dosage
1) ......................
....................
2) ......................
....................
3) ......................
....................
Are you allergic to:
- Certain types of medication
- Certain foods or drinks
- Other substances
Amount
.....................................
.....................................
.....................................
0 …………………………………………..
0 …………………………………………..
0 …………………………………………..
4. Did you have a influenza vaccination in the past year:
-No
0
Yes
0 because……………………………………..
5. Have you ever suffered a major incident and / or operation:
- No
0
Yes
0 ………………………………………………
6. Do you smoke:
-No
0
Yes
7. Do you drink alcohol:
-No
0
Yes
0 ……………… cigarettes a day- No
0 ………………. drinks a day
8. Diseases running in the family:
0 Diabetes 0 High blood pressure 0 Coronary diseases < 60 jr; 0 Cancer
0 No diseases
9. Contact person:…………………………………...............................................................
Address: Street and number:..............................................................................
Postal code and city:...........................................................................
Telephone:……………………………..................................................
ONLY COMPLETELY FILLED OUT FORMS WILL BE ACCEPTED PAG.1 T/ M 3
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Authorisation for automatic Payment:
We declare every quarter of the year an administration fee. This is independently from your visits to our
practice.
I hereby authorise Medical Centre Feenstra/Geenen, Makkink. Hulsebosch, Beeftink/van Aken/
Dirkzwager to debet my account, as required, for medical services provided for the following patients:
Surname and initials:
1. …………………………………..
2. …………………………………..
3. …………………………………..
4. …………………………………..
5. …………………………………..
6. …………………………………..
7. …………………………………..
8. …………………………………..
Date of birth:
………………………….
………………………….
………………………….
………………………….
………………………….
………………………….
………………………….
………………………….
Name and initials of the bankaccount holder:....................................................
Address: ………………………………………………………………………………
Postal code and city: …………………………………………………………………
IBAN number ………………………………………………………………………….
Email address: ………………………………………………………………………
City:
Date:
Signature:
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If the signatory doesn’t agree with the debet of the account, he/she has the possibillity to inquire his/her
bank to refund the amount.
This has be done within one week.
City:
Date:
Signature:
……………………………
……………….
……………………………….
ONLY COMPLETELY FILLED OUT FORMS WILL BE ACCEPTED PAG.1 T/ M 3
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