Patient Intake Form

Patient Intake Form for the Netherlands

Patient Intake Form Template for Netherlands

A comprehensive medical intake document used in Dutch healthcare settings to collect essential patient information, medical history, and consent for treatment. The form complies with Dutch healthcare legislation, including WGBO (Medical Treatment Agreement Act) and AVG/GDPR requirements for data protection. It serves as the initial point of contact between healthcare providers and patients, capturing crucial medical, personal, and insurance information while establishing the foundation for the healthcare provider-patient relationship and ensuring proper documentation for legal and medical purposes.

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What is a Patient Intake Form?

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.

What sections should be included in a Patient Intake Form?

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

What sections are optional to include in a Patient Intake Form?

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

What schedules should be included in a Patient Intake Form?

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) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Generate a Bespoke Document

Download a Standard Patient Intake Form

Review your own Patient Intake Form

What is a Patient Intake Form?

What sections should be included in a Patient Intake Form?

What sections are optional to include in a Patient Intake Form?

What schedules should be included in a Patient Intake Form?

Authors

Alex Denne

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