Intake form 'poliklinische apotheek'

Intake form outpatient pharmacy Amsterdam UMC, location AMC.

Personal information

Sex*

Male

Female

Nor male, nor female

Your initials*

Your name and surname*

Address*

Post code*

Town*

Your (cell) phone number*

Your e-mail address*

BSN number*

Dutch social security number

Your date of birth*

Do you have siblings born on the same date as you are?*

Yes, I have

No, I don't

Your weight*

Please specify in kilogram with one or none decimals.

Your height*

Please specify in meters, so with exactly two decimals

Name of your doctor (general practitioner)*

Name of your own pharmacy*

ma t/m za 07:30-23:00 zo en feestdagen 09:00-21:00

TK0-110 (Rode Luifel)

Telefoon: 020 - 566 3677
Fax: 020 - 566 9649
E-mail: amcapotheek@amc.nl

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