« 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* City Phone* Sex* Male Female BSN number* Insurance provider Insurance number Name previous pharmacy + location To 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?* Yes No Do you allow the inquiry for your medical history from a previous pharmacy?* Yes No Do you allow the inquiry for your laboratory data? (sodium, potasium en kidney failure)* Yes No HiddenDo you allow the inquiry for your medical history from a previous pharmacy? Yes No HiddenRegister type One time register Prolonged register Do you agree to participate in our customer satisfaction questionnaire?* Yes No Name + location of general practitioner*
