Application form MRI research

1 Patient records 2 MRI exam 3 Contraindications 4 Referring doctor 5 Voltooid

Patiënt information

Surname / Initials *

Gender *

Male

Female

Date of birth *

Address

Postal Code

Town

Phone number *

E-mail address

Citizen service number/ BSN number

Patiënt heeft geen BSN

Patient doesn't have a Dutch citizen service number (BSN).

Select this option if the patient doesn't have a Dutch citizen service number.

Insurance company/ number

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