Registration practice

We are currently closed to new patients. An exception is made for extending the family relationship, such as cohabitation with an already registered patient and newly born babies.

* = verplicht veld

First name*

Surname*

Gender*

Date of birth*

Insurance*

Insurance number*

Did you get the flu shot from your previous doctor? If so, for what reason?*

nee

Reason if flu shot received

Street*

House number*

Addition

Postal Code*

Citizen service number*

Phone number*

E-mailadress*

Name of previous GP*

City of previous GP*

Remarks

Permission*

I hereby confirm my registration with Huisarts aan de Herengracht and I give them permission to deregister me and to request my medical data from my previous GP.