It Konvintshûs | Workum GP

Our practice is open to new patients.
If you would like to register with our practice, please use the registration form (pdf) download here or collect at the counter. It is also necessary to give us permission to share your data with colleagues if necessary. You can indicate this on the registration form.

When you inform your previous GP of your move, you can also have your records sent to our practice. Don't forget to pass on the changes to your health insurance and pharmacy?

Last Page

First name *

Initials *

Surname *

Maiden name

Email address *

Phone number *

Gender *

Date of birth *

Place of birth *

Emergency contact name

Emergency contact mobile number

Street name *

House number *

Addition

Postcode *

Location *

BSN *

Health insurer *

Policy number *

Pharmacy (new) *

Previous GP *

Place name previous GP

Desired registration date *

Comments

I agree to register with this practice. *

Yes

I give permission to the practice to request my record from my previous GP/carer. *

Yes

I consent to the exchange of my medical data with healthcare partners such as the emergency department, hospital and pharmacy. *

Yes

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Working area GP practice north side

Working area GP practice south side