Clinic for Children / Praktijk voor Kinderen
Patient registration / Patiënt registratie
Clear selection
Family name / Achternaam *
Name / Voornaam *
Include all names please / Voornamen
Date of birth / Geboortedatum *
MM
/
DD
/
YYYY
BSN number / BSN nummer
Leave blank if you do not have a BSN number
Address / Adres *
Postal code / Postcode
City / Woonplaats *
Telephone number parent 1 / Telefoonnummer ouder 1 *
Telephone number parent 2 / Telefoonnummer ouder 2
Email address / Email adres *
Reason for consult / Zorgvraag
Short description / Korte uitleg
Insurance company name / Naam zorgverzekeraar *
UZOVI number Dutch insurance / UZOVI code zorgverzekeraar
Only for Dutch insurances / 4 cijfers
Insurance relation number / Relatienummer zorgverzekeraar
Only for Dutch insurances
Name of referring house doctor / Naam doorverwijzer
If applicable / indien van toepassing
Name bank account holder / Naam rekeninghouder *
Bank IBAN number / IBAN nummer bank *
This has 18 characters in total
I hereby authorise Praktijk voor Kinderen to deduct the consultation fee from the above bank account / Hierbij geeft ik toestemming aan Praktijk voor kinderen om gemaakte consult kosten te laten afschrijven van bovenstaand rekening nummer *
Required
Privacy
I am aware of the privacy statement of the clinic and am in agreement with the terms / Ik ben bewust van en accord met de privacy regeling van de praktijk - http://drbuskin.com/general/privacy-statement/ *
Required
Acute and Urgent Care/After Hours Care of your Child
I understand that the Clinic for Children is a consulting based paediatric service and patients are seen by appointment only. For all acute care I am aware that I would need to contact my house doctor or SMASH (the after hour house-doctor service) if an appointment is not available in the Clinic for Children or after hours. *
Required
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