STROOMZ Deregistration Form

When you want to deregister from the practice of your general practitioner, a deregistration form must be completed per person aged 16 and over. By completing this form, you agree with the deregistration and you agree to forward your medical files to your new general practitioner.
Pay attention! Does it concern a deregistration for a child younger than 16 and is there a co-parenting agreement?
In this case, both parents have to give permission for the deregistration. Your deregistration is only definite when both parents’ signatures are on the deregistration form.
In this case, print out the confirmation of the deregistration and send it, signed by both parents, to the general e-mail address of your health center.
Have a look here for the correct email address: https://www.sge.nl/contact.

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Deregister by date

Initials

First name

Last name *

Name by birth/ Maiden name *

Sex

Male

Female

Date of birth *

BSN (social security number) *

(Mobile) phone number *

E-mail address *

Type of identification *

Number of identification *

Is the deregistration also for family members younger than 12 years? If yes, enter the data per family member each, on one line.

New address: (only to be filled when moving house):

Are you moving house? *

Yes

Street *

House number *

Postal code *

City *

Telephone number *

Current family doctor / general practitioner

Health center *

Your family doctor / GP *

Pharmacy

Do you want to change your Pharmacy? *

Yes

No, I keep my Pharmacy

I would like to change my pharmacy to : *

The switch to an Stroomz pharmacy has now been arranged and your file will be transferred. You don't have to do anything else.

Would you also like to unsubscribe from the Stroomz Pharmacy or Stroomz Medipunt? *

Yes

New family doctor/ GP

Salutation *

Initials *

Last name *

Address *

House number *

Postal Code *

City *

Telephone number *

The above-mentioned patient agrees that his / her medical data may be sent to the new general practitioner. *

Yes

Reason of deregistration: *

Moving house

Not satisfied with current GP

Not satisfied with health center

Another reason

* = Input is required