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:

Last name:
Initials:
First name
Male / Female

Birthname

Date of birth

Have you been a patient of GC Lombok before? yesno

Identification:

BSN (Burger Service Number)

Contact details:

Street

Number

Zip code

City
Phone number

Mobile phone number

Email address

Language:

Country of birth

Do you speak Dutch? yesno

What language do you speak?

Who can interpret for you?

Insurance:

At which company are you insured?

Insurance number

Pharmacy:

My pharmacy is/will be
Lombok apotheekOther

Other pharmacy

Previous GP:

Name doctor
City
Telephone number

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

yesno

Permission exchange of medical data:

In some situations other doctors might need our information to treat you well. When you visit doctors on call or Accident & Emergency, for example. Do you agree that these doctor check your GP file, if necessary, to see what condition you have or which medication can be prescribed safeley?

Do you agree? yesno

Online services:

I would like to use the online services, such as making appointments with the general practitioner, requesting an email consultation or viewing lab results (only possible for people aged 18 and older).

Other family members:

Is there another family member already known at GC Lombok? yesno

Last name

Date of birth

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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.

Online registration

Welcome at GC Lombok

Gezondheidscentrum Lombok

Onze zorg

Uitgelicht