New Patient Intake Form

New Patient Intake Form Template for Netherlands

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Key Requirements PROMPT example:

"I need a New Patient Intake Form for my small dental practice in Amsterdam, compliant with Dutch healthcare laws, that includes detailed dental history sections and handles both adult and pediatric patients, to be implemented by March 2025."

Document background

The New Patient Intake Form is a crucial document used by healthcare providers in the Netherlands when establishing initial contact with new patients. This form must comply with multiple Dutch healthcare regulations, including the Medical Treatment Agreement Act (WGBO), the Healthcare Quality, Complaints and Disputes Act (WKKGZ), and the General Data Protection Regulation (GDPR/AVG). It collects essential information such as personal details, medical history, insurance information, and emergency contacts while securing necessary consents for treatment and data processing. The document serves as the foundation for the healthcare provider-patient relationship and creates a legal record of the patient's initial status and consent to treatment.

Suggested Sections

1. Personal Information: Basic patient details including name, date of birth, BSN (Dutch social security number), contact information, and preferred language

2. Insurance Details: Health insurance provider information, policy number, and coverage details

3. Emergency Contacts: Names and contact information for emergency contacts and family doctor (huisarts)

4. Medical History: Current medical conditions, past surgeries, chronic illnesses, and ongoing treatments

5. Current Medications: List of current medications, dosages, and known drug allergies

6. Family Medical History: Relevant family medical conditions and hereditary diseases

7. Lifestyle Information: Smoking status, alcohol consumption, exercise habits, and dietary restrictions

8. GDPR Consent Statement: Explicit consent for data processing as required by Dutch privacy laws

9. Declaration and Signature: Patient's confirmation that provided information is accurate and acknowledgment of terms

Optional Sections

1. Mental Health History: Optional section for practices that provide mental health services or require mental health background

2. Pregnancy and Gynecological History: For female patients when relevant to the type of care being provided

3. Dental History: For dental practices, including past dental procedures and concerns

4. Physical Therapy History: For physiotherapy practices, including past injuries and treatments

5. Alternative Medicine Usage: Information about any alternative treatments or therapies being used

6. COVID-19 Status: Vaccination status and history of infection (may be required during pandemic periods)

7. Cultural/Religious Considerations: Special considerations that may affect treatment options or care delivery

Suggested Schedules

1. Privacy Policy: Detailed explanation of how patient data is collected, stored, and processed in compliance with GDPR/AVG

2. Patient Rights Document: Summary of patient rights under WGBO and other relevant Dutch healthcare laws

3. Medical Information Release Authorization: Separate form for authorizing release of medical information to specified parties

4. Practice Information: Details about the practice, working hours, emergency procedures, and contact information

5. Financial Terms: Explanation of payment procedures, insurance claiming process, and financial responsibilities

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Dental Care

Mental Health Care

Physical Therapy

Alternative Medicine

Primary Care

Specialized Medical Care

Healthcare Administration

Medical Insurance

Relevant Teams

Administration

Front Desk

Medical Records

Compliance

Legal

Patient Services

Quality Assurance

Data Protection

Clinical Operations

Practice Management

Relevant Roles

Healthcare Provider

Medical Administrator

Practice Manager

Compliance Officer

Data Protection Officer

Medical Records Manager

Healthcare Quality Manager

Patient Service Representative

Medical Secretary

Healthcare Receptionist

Clinical Director

Practice Owner

Healthcare Legal Counsel

Privacy Officer

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