Subscribe With this form you register at our pharmacy: welcome! Gender Make a selection Male Female Initials First name Last name Citizen Service Number (BSN) Date of birth Address details Postal code House number House number addition Street City Mobile phone number Landline phone number Email address General practitioner (GP) Remarks I give permission to request my medical records from my current pharmacy. Yes No What is the city of the pharmacy? Wat is de naam van de apotheek? I have read the brochure 'Jouw medische gegevens beschikbaar via het Landelijk Schakelpunt (LSP) Landelijk Schakelpunt'' gelezen. Yes No I give permission for the digital availability of my medical data via the National Switch Point (LSP). Yes No I give permission for the exchange of laboratory results.? Yes No I use prescription medication. Yes No We will contact you if you use medication Which medication(s)? Which medication(s)? Which medication(s)? Medication name Medication strength How would you like to receive your medication? Pick up at the pharmacy counter during opening hours. Free 24/7 pickup from the medication dispensing machine. I would like my medication to be automatically refilled.? Add a family member living at the same address? Yes No Family member details Family member details Family member details First and last name Date of birth Citizen Service Number (BSN) Direct debitNot all medications are covered by your health insurance. It is also possible that you have outstanding orders that still need to be paid. By completing the form below, you will receive a monthly payment overview and the amount will automatically be debited from your bank account. I agree that products not reimbursed will automatically be debited from my bank account: Account holder name IBAN I am aware that by receiving medication from this pharmacy, I enter into a treatment agreement with the pharmacist. He/she is therefore obliged to provide me with proper care. What this entails is laid down in the Dutch Medical Treatment Contracts Act (WGBO). The obligations you have as a patient are also included in this law. Click here for more information. hierfor more information. I agree to the processing of my personal data. CAPTCHA Deze vraag is om te controleren dat u een mens bent, om geautomatiseerde invoer (spam) te voorkomen. Submit
