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Pret in herstel | info@pretinherstel.nl | +31 (0)70 8875 874

Personal information

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Intersertion

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Date of birth(*)

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Place of birth(*)

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Sex (*)

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Social Security Number (BSN)(*)

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Contact details

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Addition

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City(*)

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E-mail adress(*)

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Phone number

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Mobile number

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Clinic of origin

Who did you refer to?

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Naam referrer

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Therapy

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Cleandate

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Dismissal date

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Kliniek van herkomst

Name clinic

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Name referrer

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E-mail referrer / practitioner

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City of origin

Name of the City where you lived before you went to the clinic

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Street

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Zipcode

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House number

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City

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Addition

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WMO

Has a WMO been reported?

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If yes, where?

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When?

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Pret in Herstel

Bordewijklaan 38, 3rd floor
2591XR The Hague
Tel: +31(0)70 8875 874
www.pretinherstel.nl
info@pretinherstel.nl

Billing Information

Chamber of Commerce:
54067316

Bank Number:
NL56RABO 0152 70 57 59

VAT Number:
NL851143544B01

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