Practice information Team News Complaints Registration form Initials First name Preposition Sur name, and previous surname Gender GenderMaleFemale Date of birth Birthplace Marital status Marital statusMarriedUnmarriedDivorcedLiving togetherWidowedNot applicable, other Address, streetname Housenumber Postcode Town Telephone number Mobile number Email address Name former GP Address former GP Telephone number former GP BSN (Citizen service number) Name health insurance Policy number Name pharmacy Do you consent to requeste your medical records? Do you consent to requeste your medical records? Yes No Do you want to register for LSP, for the exchange of important medical information? Do you want to register for LSP, for the exchange of important medical information? Yes No I would like to receive a link for the patients potal (valid for 2 days) I would like to receive a link for the patients potal (valid for 2 days) Yes No Remarkes 7 + 6 = Apply Did you know you can give permission for LSP for the exchange of medical information youself? Go to ikgeeftoestemming.nl Newsletter Subscribe to our newsletter and stay up to date on our latest developments. Success! First Name Last Name Email Subscribe now Ask a question Name Email Address Message Submit Follow Privacy regulations and disclaimer