Registration form Mesoforte

Please correct the errors described below.

Personal information

Medical information

Which medication is currently being used? *

What other supplements are currently being used? On your own initiative or prescribed by others? *

* Bring samples of all mentioned medication & supplements to the appointment

Living conditions

Complaints

Personal characteristics

(Family) history

In chronological order, also consider: childhood diseases, dental procedures, etc.
For example: national vaccination program, HPV vaccine, flu shot and / or travel vaccinations

Food habits

What is generally eaten daily at breakfast, lunch, dinner and as a snack? Please also mention soy products, meat substitutes and other specific foods.
What is generally drunk daily at breakfast, lunch, dinner and in between?

Allergies and sensitivities

Personal case history

Specifically for (young) men

Specifically for (young) women

Specifically for children from 0 to 12 years

Signature

Therefor, please do not print this form at home!

Send this registration form to Mesoforte by clicking the 'Send' button at the bottom of this page

PRIVACY

For a good treatment it is necessary that Patricia van Houten, as your therapist, creates a file. This is a statutory duty imposed on her as a therapist by the Medical Treatment Contracts Act (WGBO). Your file contains notes about your state of health, as well as information about the tests and proposed treatments performed by your therapist. In addition, the file contains information that is necessary for your treatment. Your therapist does her best to ensure your privacy. This means, among other things, that she: • Handles your personal and your medical data carefully; • Ensures that unauthorized persons do not have access to your data. As your attending therapist, Patricia van Houten has sole access to the data in your file. With regard to this information, she also has a legal duty of confidentiality (professional secrecy). The data from your file can be used for the following purposes: • Only at your request and with your explicit permission to inform other health care providers; for example when the therapy is completed, your file is handed over at your request, or when you refer to another therapist; • For use for observation by a fellow colleague, during your therapist's absence. These observer(s) are also covered by professional secrecy and use the same rules regarding your privacy; • For the anonymised use during peer review; • Some of the data from your file is used for the financial administration, to be able to produce an invoice. To be allowed to hand over medical information to your general practitioner and/or other therapists/therapists you will be asked for permission separately. If your therapist wants to use your data for another reason, prior to this she will explicitly ask you for permission to do so. The data in a client file is kept for 15 years, as required by the aforementioned law on the medical treatment agreement. PRIVACY in relation to your INVOICE The invoice, which you will receive following your appointment, contains details that are required by health insurers, so that you can declare this bill to your health insurer. These details include your: • Name, address and place of residence; • Date of birth; • Date of treatment; • Invoice number; • A brief description of the treatment; • The costs of the consultation. EXPLANATION By means of this form you are explicitly informed which data your therapist stores in your client file and what your therapist does with this data. By signing the registration form, you will give your therapist (Patricia van Houten, Mesoloog D.M.) permission to store your data in order to be able to implement the requested support, as well as to comply with legal obligations. You can withdraw this permission at any time.

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