The Patient Intake Form is a fundamental document used across Belgian healthcare facilities to initiate patient care relationships and maintain accurate medical records. This document is required when a patient first engages with a healthcare provider or facility in Belgium, collecting essential information needed for proper medical care while ensuring compliance with the Belgian Patient Rights Act, GDPR, and local healthcare regulations. The form must be available in French, Dutch, or both languages depending on the facility's location within Belgium, and includes sections for personal information, medical history, consent declarations, and privacy notices. It serves as the cornerstone of patient documentation and must be periodically updated to reflect any changes in the patient's condition or personal information.
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1. Patient Personal Information: Basic identification details including name, date of birth, national registry number, contact information, and preferred language
2. Emergency Contact Information: Details of primary and secondary emergency contacts
3. Insurance Information: Health insurance details, including provider, policy number, and coverage type
4. Medical History: Current medical conditions, past surgeries, chronic illnesses, and family medical history
5. Current Medications: List of current medications, dosages, and known drug allergies
6. Primary Care Provider Information: Details of current general practitioner and other relevant healthcare providers
7. GDPR Privacy Notice: Required information about data processing, storage, and patient rights under GDPR
8. Consent Declarations: Patient consent for treatment, data processing, and information sharing
1. Language Preference Declaration: Required only in Brussels region where patients must specify their preferred language for medical communications
2. Specialist Care Information: Include when patient is under specialist care or being referred to specialists
3. Payment Preferences: Include for private practices or when direct billing is offered
4. Cultural/Religious Considerations: Include when facility offers specific accommodations for cultural or religious preferences
5. Research Participation: Include if the facility conducts medical research and wishes to maintain a database of potential participants
1. Privacy Policy: Detailed privacy policy compliant with GDPR and Belgian Privacy Act
2. Patient Rights Summary: Summary of patient rights under Belgian law
3. Hospital/Practice Policies: Relevant facility policies including appointment cancellation, payment terms
4. Fee Schedule: List of common procedures and associated costs (for private practices)
5. Medication History Form: Detailed form for listing current and past medications
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