Registration form - Osdorp Dokters

Welcome to our practice Osdorp Doctors.

We are open for patients living in zip codes: 1060,1062,1065,1066, 1068 and 1069

Initials
Nickname *
Last name *
Maiden name
Sex *
ManVrouw
Date of birth *
Identity Document *
PassportID
Identity document number *

Address information

Street *
House number *
zip code *
Place *
phone number
Mobile number *
E-mail *
Health insurance *
Insurance number *
Citizen service number *

Details of previous GP

Name *
Address
Place

Details of your new pharmacy

Naam
Adres
Plaats

Requesting your medical information from your previous GP is necessary for the provision of medical care to you

I give permission to request medical information from my previous GP
YesNo
Other comments

Arrange your permission for the exchange of your medical data by your GP and pharmacy" and then use this site https://www.volgjezorg.nl/

Verification

To get less spam via our forms we ask you to type any two number *for example : 12
Deze ruimte is voor spam beveiliging - <strong>a.u.b. blanko laten</strong>: