Registration form Registration form Stap 1 van 5 20% For registration in our practice, please fill in this registration form. After 1-2 days we will contact you to complete your registration in our practice. Please bring your ID and health insurance number to this appointment. Personal dataGender*MaleFemaleLast Name*Initials*First name*Date of birth* Place of birthProfessionMarital status Address dataStreet*House number*Postal Code*Recidence*Phone number*E-mail* Insurance and BSN-Number BSN number*Health Insurance*Insurance number*ID number: Passport/Drivers license*Preferred pharmacy Details of the previous GP / GP at your other home addressNameAddressResidencePhone numberOnly for registration minors (<16 year of age): Do both parents agree with registration at praktijk Lelystraat?JaNee Regioviewer: Share lab or radiology results also with huisartspraktijk LelystraatYesNoPoint "yes" if you agree that if a medical specialist did recent lab tests or radiology tests, huisartspraktijk Lelystraat could view the result in case of consulting us.LSP: Junction with Urgent Care CentreYesNoIn case of emergency in evenings, night or weekend, the Urgent Care Centre can do consultations. Point "Yes" if you agree that a doctor is able to see the GP file in case of consultation the Urgent Care Centre. See also: https://www.volgjezorg.nl/enMijngezondheid.netJaNeePoint "Yes" if you are interested in Mijngezondheid.net which is part of eHealth: You as a patient can ask to repeat medication online, do e-consultation or see part of your medical file. You need a DigiD for this application. Other comments:RecaptchaCommentsDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.