Online registration

Use the form below to register yourself (and your family members) as a patient with the general practitioners at GC Lombok.

Please fill out a separate form for every family member.


Personalia:





Identification:


Contact details:








Insurance:



Pharmacy:


Previous GP:




Herewith I give you my permission to ask my previous doctor to send my file to GC Lombok.

yesno

Permission exchange of medical data:

Do you agree? yesno


Other family members:


Welcome at GC Lombok

After filling out this form you will receive an email message with a questionnaire attached, concerning your medical history. Please answer the questions and leave the document at the clinic’s welcome desk.