Registration form.

In the Netherlands there is free choice of pharmacy. Therefore, in addition to your registration with MYCB1 Pharmacy, you can stay registered with your current pharmacy. After you have registered with MYCB1 Pharmacy, you will be called within 1 working day by one of our assistants. He or she will go through your details and your medication with you (including ID check, make sure you have your ID at hand).

Full Name *

First

Last

Gender *

Date of birth *

BSN number *

Street *

House number *

City *

Zip Code *

Phone Number *

Email address *

General practitioner information

First

Last

Current pharmacy information

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Last

Comments and/or questions

Toestemming

I authorize MYCB1 Apotheek to request my complete medication record from my previous pharmacy.
I give permission for MYCB1 Apotheek to share my medication information with other health care providers via the LSP so that my other health care providers can access my medication from MYCB1 Apotheek if necessary. See www.volgjezorg.nl.
I give permission to MYCB1 Apotheek to view laboratory results and kidney function so that the pharmacy can assess whether I am still taking the correct medication in the correct dosage.
I consent to the use of ALETTA 1.0 app to monitor my quality of life. Read this form.
I give permission to MYCB1 Apotheek to send my medication by mail (through the mailbox if it fits).