You wish to register as a patient in our Health Centre, Huisartsenpraktijk Blaak.

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Dear Sir / Madam, You wish to register as a patient in our Health Centre, Huisartsenpraktijk Blaak. You are kindly requested to complete these forms and return them in person at the reception, accompanied by a copy of your identity card / passport and health insurance card. Your registration cannot be completed without these documents. We would like to have these following documents, completed and returned to us: 1. New patient registration form 2. Medical history form 3. Consent form for medical data in LSP 4. Form to sign up for MijnGezondheid.net 5. Copy Identity card or passport 6. Copy Health Insurance registration or card Furthermore, please call your former family doctor and ask them to send us your medical record digitally. Your registration with your previous family doctor will be deregistered upon registration in our GP Practice, since Health Insurance Care does not allow patients to be registered at more than one family doctor at the same time. We will declare your healthcare costs according to the set tariffs by NZA, directly with your health insurance company. Your insurer will reimburse it, possibly with your deductible/excess. For healthcare costs not reimbursed by your insurance, you will receive the bill yourself. Kind regards, Huisartsenpraktijk Blaak Blaak 24b 3011 TA Rotterdam T: 010 411 12 07 F: 010 412 95 06 E: info@huisartsblaak.nl W: www.huisartsblaak.nl

NEW PATIENT REGISTRATION FORM (patient s details) Surname/family name + Title Maiden name (if applicable) First names (+ forename) Date of birth BSN (Citizen Service No.) Marital status Home Address (Street + No.) Postal Code + City Telephone Number(s) E-mail address Insurance Company Insurance Number Name Preferred Pharmacy Previous Physician s Name Religion Nationality Preferred languages Education or Profession Occupational status Donor card Living will / Euthanasia : Mr. / Mrs. /Miss /Ms..... :... :... :... :... :... :... :... : :... : working/ unemployed / disabled / retired /. : Yes / No : Yes / No Consent with the transfer of medical records (if applicable) YES* I hereby give consent to my previous physician, doctor... to transfer my medical file digitally via ZorgFileTransfer to my new general practicioner, Huisartsenpraktijk Blaak, dokter V.T. Nguyen, praktijk AGB-code 01-058963 Rotterdam, (date) Signature of patient:... *If you do not consent to the transfer of your medical file to Huisartsenpraktijk Blaak, we unfortunately will be unable to provide adequate care; therefore we will not accept your registration.

MEDICAL HISTORY FORM We would appreciate if you would fill out this form concerning your health. If your household consists of more than one person, each person should complete the form separately, regardless of age. Which of the following conditions are you currently being treated or have been treated for in the past (please check): Diabetes High cholesterol High blood pressure Eye disorder Heart and vascular disease Kidney / bladder problems Seizures Seasonal allergies Liver problems / Hepatitis Stroke Neurological problems Anaemia or blood problem Cancer Joint problems Ulcers / colitis Thyroid problems Lung problems (asthma / COPD) Mental illness / psychological problems Please describe any current or past medical treatment not listed above. Please list your past surgeries. Are you currently being treated by a specialist? If yes, which specialist and where?. Have you ever been hospitalized or admitted to surgery? If yes, what for and when..

Do you currently use medications? If yes, please list name of the drug, strength and dosage... Are you allergic to penicillin or any other drug (substance)? If yes, which medicine or (substance) drug? Do you smoke? Yes, cigarettes per day No, I have never smoked. Yes, formerly smoked, but quit smoking as of: Are there (hereditary) conditions in the family? If yes, which illnesses and which family member (including parents and children)? Diabetes Lung problems (asthma / COPD) High blood pressure From age: High cholesterol Heart and vascular disease From age: Stroke or cerebral haemorrhage From age: Cancer (kind of cancer) Mental illness / psychological problems Stomach, abdominal, liver problems Joint problems Kidney / bladder problems Thyroid problems If there is any other important information for the family doctor to know, you can state that here: Thank you in advance for completing this questionnaire.

Permission form Your medical data available through the LSP YES I do authorize the below-mentioned healthcare provider making my data available through the LSP. I have read all the information contained in the Your medical data available through the LSP (National Exchange Point) brochure. NO I do not authorize the below-mentioned healthcare provider making my data available through the LSP. I have read all the information contained in the Your medical data available through the LSP (National Exchange Point) brochure. GP or pharmacy details Which healthcare provider does the form concern? my GP my pharmacy Name: Huisartsenpraktijk Blaak / dhr. V.T. Nguyen Address: Blaak 24 Postcode and town: 3011 TA Rotterdam Pharmacy: Medsen Apotheek Lagaay Westblaak /. My details Complete the below details. Do not forget to sign the form. Family name: Initials: M F Address: Postcode and town: Signature: Date: Do you wish to give permission with respect to your children? For children up to age 12: as a parent or guardian, you have to give your permission. Please use this form. For children aged 12 to 16 who wish to give their permission: both the parent or guardian and the child need to sign the form. Children aged 16 and over need to give permission themselves and complete a separate form. Details of my children Complete the below details of the children with respect to whom you wish to give permission. Do not forget to provide your own signature. Do you have more than two children? Please complete a new permission form. Personal and family name: M F YES NO Signature child: Personal and family name: M F YES NO Signature child: Date: Signature parent of guardian: Submit this form to the GP of pharmacy your permission concerns.

ONLINE COMMUNICATION WITH YOUR FAMILY DOCTOR Do you have a health related question via email for your family doctor? Or would you like to make an online appointment with your family doctor? As of now, this is available on MijnGezondheid.net, a secured patient portal for online communication between patient and family doctor. YES I would like to sign up to MijnGezondheid.net First name & Surname: Mobile phone number*: _06- Email address: * please note that only a Dutch 06 number will be accepted by MijnGezondheid.net Please return this form to our staff member or apply online by sending an email to: info@huisartsblaak.nl After we have activated it, you will receive a confirmation email. Once you receive our e-mail, you can log in to MijnGezondheid.net through our website www.huisartsblaak.nl by using your DigiD combined with an extra SMS-verification code.

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