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Menu
  • Home
  • Blog
  • Videos
  • General
    • About us
    • Free PDF ebook!
    • Intake (consultation)
    • Disclamer
    • Consultation fee
    • Research costs
    • Treatment costs
    • Terms
    • Payment terms
    • Privacy Policy
  • Forms
    • Request
    • Newsletter subscription
    • Intake
      • Intake form digital
      • Download Intake Dutch
      • Download Intake English
    • Informed consent
  • Shopping Cart
  • Contact
    • Telephonist
    • Callback request
    • Partners
  • Review

Intake form

Intake

Step 1 of 2

50%
DD slash MM slash YYYYY
Handler(Required)
Choose which practitioner you have the intake with
Enter the name of your company if it should appear above the invoice.
Patient name(Required)
DD slash MM slash YYYYY
Enter your date of birth
Patient address(Required)
Enter your address information here
Enter your gender here
Please enter your email here. This e-mail address must not have been used before. For example, if you want to add your partner or child with the same e-mail address place the date of birth of your partner or child in front of the e-mail address. E.g.: 301269ditismijnemailadres@hotmail.com. Below you can enter the e-mail address where the invoice can be e-mailed to.
Password
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E-mail to which the invoice should be sent.
Enter the phone number of your landline phone
Enter the phone number of your cell phone. A phone number is required
Please enter your BSN number
Enter your main complaints
Diseases that run in the family (asthma, eczema, allergies, cancer, diabetes, rheumatism, etc.,). Mother, father, grandparents (father's and mother's side), children and siblings
Operations and hospitalizations gone through (include year)
Please list here what medications you take, for how long and how much (antibiotics, paracetamol, corticosteroids, birth control pill, creams, etc.).
Please list here which dietary supplements you use, for how long and how much?
Vaccinations as a child and later vaccines (related to travel, flu prevention, please include years, etc.)
Particulars before/during/after your own birth (e.g., mother's medication use during pregnancy, emotional events, childbirth initiation, pain management, etc.):
Do you maintain a diet and if so what diet(s)
How much do you drink per day, of water or (herbal) tea
Smoking, alcohol, weed, or other drug use, per day or per week:
Do you have certain Allergies/ hypersensitivities (food, supplements and medications?):
We recommend that you always inform your doctor about your treatment plan.
GP name(Required)
Enter the name of your primary care physician here
GP address(Required)
Enter the address of your primary care physician again
I agree to the following(Required)
Drag files here or
Allowed file types: pdf, Max. file size: 8 MB, Max. number of files: 10.
    Here you can upload your files (think blood results etc). PDF only
    Reset signature Signature locked. Reset to sign again
    Place your digital signature here. Click in the box and you can sign with the mouse.

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