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Intake Form

Intake Form Template for Belgium

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Key Requirements PROMPT example:

Intake Form

"I need a GDPR-compliant medical practice Intake Form in Dutch for my physiotherapy clinic in Brussels, launching in March 2025, that includes sections for medical history, insurance details, and explicit consent for sharing information with referring doctors."

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Document background
The Intake Form serves as a crucial first step in establishing a formal relationship between service providers and clients in Belgium. It is designed to collect necessary information while ensuring compliance with Belgian privacy laws, GDPR, and sector-specific regulations. The document must be available in appropriate official languages (Dutch, French, or German) depending on the region of use. This intake form includes mandatory privacy notices, explicit consent mechanisms, and data processing declarations as required by EU and Belgian law. It's particularly important for regulated sectors where detailed client information is necessary for service provision, such as healthcare, legal services, or financial consulting. The form should be structured to collect only essential information relevant to the service being provided, following the data minimization principle of GDPR.
Suggested Sections

1. Personal Information: Basic identification details including name, date of birth, national register number (if required), contact information

2. Contact Preferences: Preferred methods of communication and language choice

3. Privacy Notice: GDPR-compliant explanation of how personal data will be processed, stored, and used

4. Consent Declarations: Explicit consent options for data processing, marketing communications, and other specific purposes

5. Service Requirements: Details of the service or assistance being sought

6. Declaration of Truth: Statement confirming that all provided information is accurate and complete

Optional Sections

1. Medical Information: For healthcare-related services - includes relevant medical history, conditions, medications

2. Financial Information: For financial services or where payment arrangements are needed

3. Emergency Contacts: When ongoing service relationship requires emergency contact information

4. Professional Qualifications: For professional services or employment-related intake

5. Special Assistance Requirements: For accessibility or special needs accommodations

6. Insurance Information: When service involves insurance coverage or claims

7. Previous Service History: For returning clients or where service history is relevant

Suggested Schedules

1. Privacy Policy: Detailed privacy policy document as required by GDPR

2. Terms and Conditions: General terms and conditions of service provision

3. Service Price List: If applicable, current pricing for services

4. Required Documents Checklist: List of additional documents that need to be provided

5. Consent Forms: Additional specific consent forms that may be required for particular services

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Legal Services

Financial Services

Education

Social Services

Professional Services

Insurance

Mental Health

Physical Therapy

Dental Care

Business Consulting

Real Estate

Non-Profit Organizations

Relevant Teams

Administration

Compliance

Client Services

Legal

Operations

Customer Support

Data Protection

Reception

Quality Assurance

Risk Management

Front Office

Records Management

Relevant Roles

Office Manager

Compliance Officer

Data Protection Officer

Client Services Manager

Healthcare Administrator

Legal Secretary

Financial Advisor

Human Resources Manager

Practice Manager

Intake Coordinator

Customer Service Representative

Operations Manager

Administrative Assistant

Professional Services Manager

Client Relations Manager

Industries
GDPR (General Data Protection Regulation): EU regulation 2016/679 on data protection and privacy, crucial for handling personal information in intake forms
Belgian Privacy Act: Law of 30 July 2018 on the protection of natural persons regarding the processing of personal data, implementing GDPR in Belgian law
Belgian Language Decree: Laws of 18 July 1966 on the use of languages in administrative matters, requiring forms to be available in official languages depending on the region
Book VI of the Belgian Code of Economic Law: Regulations on market practices and consumer protection, including requirements for transparency and fairness in business-consumer relationships
Belgian Anti-Discrimination Law: Law of 10 May 2007 prohibiting discrimination based on protected characteristics, ensuring intake forms don't contain discriminatory elements
Belgian Electronic Commerce Law: Book XII of the Code of Economic Law regarding electronic commerce, applicable if the intake form is digital
Professional Services Regulations: Specific regulations depending on the sector (healthcare, legal, financial services) that may impose additional requirements on intake forms
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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