Pharmacy Registration

By completing the below registration form, you are automatically registered at Apotheek Skagerrak.

Any amendments or changes can also be communicated through the below registration form.

Please may we kindly ask you to complete a separate registration form per individual.

Your personal information is important to us and will be treated according to privacy regulations.

General Practitioner

(Huisarts/Family Physician)

Last Name

Initials First Name(s)

First Name(s)

(Please for children below 18YRS)

Date of Birth

Day / Month / Year

Gender

Male

Female

Other

BSN

(Citizen Service nr)

Address and Contact Details

Street

Street Number

Postal Code

City

Phone number

E-mail address

Overview of Medication

Overview and control of medication is one of the most important responsibilities at Apotheek Skagerrak. Some medication might not be allowed to be taken together with some others or may not be applicable or appropriate for you personally That is why Apotheek Skagerrak needs to be informed of the entire current medication you are taking.

To ensure an optimal overview and control over your medication, please may we ask you to complete the following 4 statements:

I give Apotheek Skagerrak permission to request my complete medication file from my current pharmacy.

Yes

Previous Pharmacy

City of previous Pharmacy

I give Apotheek Skagerrak permission to exchange relevant data with other healthcare providers (such as laboratory results and measurement data).

Yes

I give permission to Apotheek Skagerrak to make my medication data available for consultation by other healthcare providers such as the out-of-hours GP and service pharmacy.

Yes

I give Skagerrak Pharmacy permission to place medication in the 24/7 collection machine (except for refrigerator products, incontinence, medication for the first time).

Yes

Important Information / Remarks

Is there anything else you wish to share with Apotheek Skagerrak?

For example: allergies, history, sensitivity, illness, pregnancy etc.