Register

I want to register at location * WestermarktBilderdijkMaasstraatStadionpleinOosterparkSpaarndammerdijk

Personal data

Gender * MaleFemale
Lastname *
Maidenname
Initials *
First name
Birth date (dd-mm-yyyy)* - -
Street *, number *, additions
Zipcode *
City *
Phonenumber *
Mobile
E-mail *

Insurance

Your health insurance *
Insurance number *
Social security number *
Is your partner already registered? * YesNoNot applicabley

Previous doctor

Name *
Street, number, additions
Zipcode
City
Do you authorize us to obtain your medical records from your previous doctor? * YesNo
Do you have a medical indication for the flu shot? * No medical indication65 years and olderHeart diseasePulmonologyDiabeteskidney patientsRegular boilsReduced resistance by other diseases
How did you get into contact with us? Through friends and/or acquaintancesThrough internetOther, namely...
I have read the privacy statement and agree with it (privacy statement).