« Terug naar vorige pagina Join us (English) Bekijk Nederlandse vertaling van dit formulier. First name*Last name*Date of birth*Email address*Address*Postal code*CityPhone*Sex* Male Female BSN number*Insurance providerInsurance numberName previous pharmacy + locationTo provide proper medication security, the following is of importance Open brochureDo you agree to make your data available for consultation by other health care providers through the LSP as indicated in the brochure?*YesNoDo you allow the inquiry for your medical history from a previous pharmacy?*YesNoDo you allow the inquiry for your laboratory data? (sodium, potasium en kidney failure)*YesNoDo you allow the inquiry for your medical history from a previous pharmacy? Yes No Register typeOne time registerProlonged registerDo you agree to participate in our customer satisfaction questionnaire?*YesNoName + location of general practitioner*