Join us (English)

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 brochure
Do 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
Do you allow the inquiry for your medical history from a previous pharmacy?
- Yes
- No
Register type
- One time register
- Prolonged register
Do you agree to participate in our customer satisfaction questionnaire?*
- Yes
- No
Name + location of general practitioner*