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:








    Language:



    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


    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:


    To prevent spam submissions, please enter the following code.

    captcha

    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.