Barrett Coördination Center (MDL)
This form is intended for specialists. Since 2025, all patients with a Barrett-esophagus in the Netherlands must be registered with the Barrett coordination center. After registering via this form, the patient will receive an information folder and a consent form for the central registration via the Barrett coordination center. If you have any questions, please contact us via: Barrettaanmeldingen@nki.nl.
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Nederlands
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Refer patient to
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Outpatient clinic
Radiotherapy
Barrett Coördination Center (MDL)
Referrer data
Referrer name
*
Name institution
*
Specialism
Email
*
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Phone number
*
Contact person for additional data
Patient data
Last name
*
Initials
*
Gender
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Male
Female
*
Date of birth
*
mm-dd-yyyy
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Address
*
House nr.
/
Addition
*
Postcode
*
City
*
Phone number
*
Email
Invalid email address
Diagnosis/suspicion
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Barrett low risc patient (ijsbreker patient)
Barrett medium risc patient (Surveillance patient)
Barrett high risc patient
Request for pathologie revision
*
Registration materials
Refferal letter
Only pdf- en Word files are allowed.
Reports
(Imaging, Scopy, Pathology and/or OR)
Only pdf- en Word files are allowed.
Only pdf- en Word files are allowed.
Only pdf- en Word files are allowed.
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