UHP - general registration form 1 van 7 Volgende Personal data Volgende Children Volgende Your situation Volgende Drug use Volgende Your (medical) history Volgende Signature Volgende Completion project.general_error_message Salutation Mr. Mrs. I don't identify as either a man or a woman Your initials Your given name Your surname Street name and house number Zip code Place name Your mobile telephone number Your e-mail address Your date of birth Place of birth Your social security number ("BSN") Upload a proof of your insurance Do you have: Dutch health insurance? Make a picture of the backside of the insurance card. AON? Make a picture of the insurance certificate stating the expiry date of the certificate. EHIC? Make a picture of the backside of the insurance card. Upload Versleep bestand naar hier of Selecteer bestand Verwijder bestand The name of the health insurance company Insurance number Your previous General Practitioner Your pharmacist What language do you prefer to comunicate in? English Dutch Do you already have "Mijn Dossier"? Yes No You have "mijn Dossier" when you have been treated at Amsterdam UMC What number "Mijn Dossier"do you have? Living situation Don't want to share (yet) Single Married Divorced Living together Widow(er) Roommate Do you have children living with you? Yes No Next step
