Patient Intake Form

Patient Intake Form Template for Netherlands

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Key Requirements PROMPT example:

"I need a Patient Intake Form for my dermatology practice opening in March 2025, which should include detailed sections on skin conditions, allergies, and family history of skin diseases, while complying with Dutch healthcare regulations."

Document background

The Patient Intake Form is a fundamental document used across healthcare settings in the Netherlands to initiate the provider-patient relationship and ensure compliance with Dutch healthcare regulations. This document is typically used during a patient's first interaction with a healthcare provider or when significant updates to patient information are required. The form collects essential information including personal details, medical history, insurance information, and necessary consents while adhering to the WGBO (Medical Treatment Agreement Act) and AVG/GDPR data protection requirements. It serves multiple purposes: establishing the legal basis for treatment, documenting patient history, ensuring proper insurance registration, and creating a foundation for ongoing medical care. Healthcare providers use this information to deliver appropriate care while maintaining compliance with Dutch healthcare quality standards and privacy regulations.

Suggested Sections

1. Personal Information: Basic patient details including name, date of birth, BSN number, contact information, and identification details

2. Insurance Information: Health insurance provider details, policy number, and coverage type as required by Zorgverzekeringswet

3. Emergency Contacts: Names and contact information for primary and secondary emergency contacts

4. General Health History: Overview of past medical conditions, surgeries, and chronic conditions

5. Current Medications: List of current medications, dosages, and prescribing physicians

6. Allergies and Reactions: Documentation of known allergies to medications, materials, or substances

7. Family Medical History: Relevant family medical history for hereditary conditions

8. Privacy Statement: GDPR/AVG compliant privacy notice explaining how personal data will be processed

9. Consent Declaration: Patient's consent for treatment and data processing as per WGBO requirements

Optional Sections

1. Lifestyle Information: Optional section for collecting information about smoking, alcohol use, exercise, and diet - relevant for specific medical specialties

2. Previous Healthcare Providers: Details of previous healthcare providers and permission to request records - useful for new patient transfers

3. Specialist Care Information: Information about current specialist care providers - relevant for patients with complex medical needs

4. Pregnancy/Gynecological History: Specific section for female patients when relevant to care

5. Mental Health History: Detailed mental health history - included when relevant to the specific healthcare service

6. Cultural/Religious Preferences: Patient's cultural or religious preferences that may affect medical care

7. Communication Preferences: Preferred language and communication method for appointments and medical information

Suggested Schedules

1. Medical History Questionnaire: Detailed questionnaire about specific medical conditions and history

2. Medication List Template: Structured format for listing current medications and dosages

3. Privacy Policy: Detailed privacy policy document compliant with AVG/GDPR requirements

4. Patient Rights Document: Overview of patient rights under Dutch healthcare law (WGBO)

5. Practice Information: Information about the healthcare practice, including contact details, emergency procedures, and complaint procedures as required by Wkkgz

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 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

Primary Care

Specialist Care

Mental Healthcare

Dental Care

Physical Therapy

Alternative Medicine

Occupational Health

Rehabilitation Services

Relevant Teams

Reception

Administration

Medical Records

Compliance

Quality Assurance

Patient Services

Clinical Operations

Legal

Data Protection

Healthcare Operations

Relevant Roles

General Practitioner

Medical Specialist

Practice Manager

Healthcare Administrator

Medical Secretary

Compliance Officer

Privacy Officer

Quality Manager

Nurse Practitioner

Physician Assistant

Intake Coordinator

Medical Records Manager

Healthcare Quality Officer

Patient Service Representative

Legal Counsel

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