Intake form

Intake

Step 1 of 2

Date of intake

Handler(Required)

Michael van Gils

Ann van Veen

Choose which practitioner you have the intake with

Company

Enter the name of your company if it should appear above the invoice.

Patient name(Required)

Prefix First name Surname

Date of birth patient(Required)

Enter your date of birth

Patient address(Required)

Street + house number City of Postal code Country

Enter your address information here

Gender patient

Enter your gender here

E-mail address patient registration(Required)

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

Enter password Confirm password

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Email address

E-mail to which the invoice should be sent.

Landline phone

Enter the phone number of your landline phone

(Mobile) phone(Required)

Enter the phone number of your cell phone. A phone number is required

BSN number

Please enter your BSN number

Complaints(Required)

Enter your main complaints

Diseases

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

Operations and hospitalizations gone through (include year)

Medicine

Please list here what medications you take, for how long and how much (antibiotics, paracetamol, corticosteroids, birth control pill, creams, etc.).

Nutritional supplements

Please list here which dietary supplements you use, for how long and how much?

Vaccinations

Vaccinations as a child and later vaccines (related to travel, flu prevention, please include years, etc.)

Details

Particulars before/during/after your own birth (e.g., mother's medication use during pregnancy, emotional events, childbirth initiation, pain management, etc.):

Diet

Do you maintain a diet and if so what diet(s)

Moisture intake

How much do you drink per day, of water or (herbal) tea

Addiction

Smoking, alcohol, weed, or other drug use, per day or per week:

Allergies/ hypersensitivities

Do you have certain Allergies/ hypersensitivities (food, supplements and medications?):

The primary care physician may receive a copy of the treatment plan?(Required)

We recommend that you always inform your doctor about your treatment plan.

GP name(Required)

Title First name Surname

Enter the name of your primary care physician here

GP address(Required)

Street + house number City of Postal code Country

Enter the address of your primary care physician again

I agree to the following(Required)

I know that BeterKliniek recommends following treatments, prescriptions and advice from your (family) doctor or specialist and informing them about the treatment as well.

I authorize BeterKliniek to use my e-mail address for correspondence regarding my treatment or related information such as a newsletter.

I know that consultations are not always or only partially reimbursed.

I know that examinations are not always or only partially reimbursed.

I know BeterKliniek can suggest an integrative/ complementary/ alternative treatment plan.

I know that I follow all advice out of my own choice and self-responsibility.

Upload files

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

Signature

Place your digital signature here. Click in the box and you can sign with the mouse.

Intake

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