Registration form for new patients  
This form is intended for referring specialists and general practitioners. We ask that you complete this form as completely as possible and include all relevant documentation.
After sending this form, our planning department will process the data and the patient will be invited to the most appropriate outpatient clinic for this problem. If you have any questions, please call the following phone number:
  • +31 20 512 9111
Fields with a * are required.
 
  Change language
  Refer patient to
Referrer data Referrer
  Referrer name *
  Name institution *
  Specialism
  Email
  Phone number
  Contact person for additional data
  Remarks
     
     
Patient data Last name *
  Initials *
  Gender *
  Date of birth *  mm-dd-yyyy
  Address *
  House nr. /  Addition *  
  Postcode *
  City *
  Phone number *
  Email
  SSN *
  Already been in the AVL?
  Diagnosis/suspicion *
   
  Treatment *
 
     
Appointment confirmation Send confirmation to


 
Reference materials Reference letter
  If the referral letter is not (yet) available, describe here question and previous investigations performed
  Reports  
(Imaging, Scopy, Pathology and/or OR)
   
 
   
   
   
     
 
  Type the code for verification
  *