Legal Templates
Patient Declaration Form

Patient Declaration Form for the Netherlands

Patient Declaration Form Template for Netherlands

A comprehensive Patient Declaration Form compliant with Dutch healthcare laws and EU regulations, specifically designed for use in healthcare settings within the Netherlands. This document captures essential patient information, medical history, consent declarations, and acknowledgments of patient rights. It serves as a formal record of patient declarations and consent while ensuring compliance with the Medical Treatment Agreement Act (WGBO), GDPR/AVG, and other relevant Dutch healthcare legislation. The form includes provisions for data protection, privacy rights, and medical information sharing, making it suitable for use across various healthcare settings in the Netherlands.

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What is a Patient Declaration Form?

The Patient Declaration Form is a fundamental document required in Dutch healthcare settings to establish the formal relationship between healthcare providers and patients. This document is designed to comply with Dutch healthcare regulations, including the Medical Treatment Agreement Act (WGBO), the Healthcare Quality, Complaints and Disputes Act (Wkkgz), and the General Data Protection Regulation (GDPR/AVG). The form is typically completed when a patient first engages with a healthcare provider or facility, or when significant updates to patient information or consents are needed. It includes essential patient information, medical history declarations, consent statements, privacy acknowledgments, and emergency contact details. The Patient Declaration Form serves multiple purposes: it ensures legal compliance, documents patient consent, protects both patient and provider rights, and facilitates proper medical care within the Dutch healthcare system.

What sections should be included in a Patient Declaration Form?

1. Patient Information: Basic personal details including name, date of birth, BSN number, address, and contact information

2. Emergency Contact Details: Information about whom to contact in case of emergency

3. General Practitioner Information: Details of the patient's huisarts (GP) and any other relevant healthcare providers

4. Medical History Declaration: Brief overview of relevant medical history, current medications, and allergies

5. Consent Declarations: Standard consent statements regarding medical treatment, information sharing, and data processing

6. Privacy Statement: Declaration regarding the processing of personal data in accordance with GDPR/AVG

7. Patient Rights Acknowledgment: Confirmation that the patient has been informed of their rights under Dutch healthcare law

8. Signature Section: Space for patient signature, date, and location

What sections are optional to include in a Patient Declaration Form?

1. Insurance Information: Details of health insurance provider and policy number - optional if not relevant for the specific healthcare setting

2. Language Preference: Preferred language for communication - relevant in areas with significant international populations

3. Research Participation: Optional consent for participation in medical research or data usage for research purposes

4. Photography Consent: Optional permission for medical photography or recording - relevant for specific treatments or procedures

5. Religious/Cultural Preferences: Space to indicate any religious or cultural considerations that may affect treatment

6. Organ Donation Declaration: Optional section for indicating organ donation preferences

What schedules should be included in a Patient Declaration Form?

1. Information Brochure: Patient information brochure explaining key rights and responsibilities

2. Privacy Policy: Detailed privacy policy explaining how personal data is processed

3. Medical Procedures List: List of common procedures and treatments that may be performed

4. Hospital/Clinic Rules: Overview of relevant facility rules and regulations

5. Complaint Procedure: Information about how to file complaints or concerns

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

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Jurisdiction

Netherlands

Publisher

Genie AI

Document Type

Declaration Form

Sector

Compliance

Cost

Free to use
Relevant Industries

Healthcare

Medical Services

Hospitals

Primary Care

Specialist Care

Mental Health Care

Dental Care

Physical Therapy

Alternative Medicine

Emergency Care

Long-term Care

Relevant Teams

Legal

Compliance

Medical Administration

Patient Services

Quality Assurance

Medical Records

Registration

Clinical Operations

Privacy

Healthcare Operations

Relevant Roles

Medical Director

Healthcare Administrator

Physician

Nurse Practitioner

General Practitioner

Medical Specialist

Compliance Officer

Privacy Officer

Legal Counsel

Medical Records Manager

Patient Registration Coordinator

Healthcare Quality Manager

Patient Services Manager

Clinical Director

Practice Manager

Industries
Wet op de geneeskundige behandelingsovereenkomst (WGBO): The Medical Treatment Agreement Act - regulates the rights and obligations between healthcare providers and patients, including informed consent requirements and information rights
Wet op de beroepen in de individuele gezondheidszorg (BIG): Individual Healthcare Professions Act - defines which healthcare professionals are authorized to perform certain medical procedures
Algemene Verordening Gegevensbescherming (AVG/GDPR): General Data Protection Regulation - European privacy law governing the processing of personal data, with specific provisions for health data
Wet kwaliteit, klachten en geschillen zorg (Wkkgz): Healthcare Quality, Complaints and Disputes Act - ensures quality of care and proper handling of complaints in healthcare
Wet aanvullende bepalingen verwerking persoonsgegevens in de zorg: Additional Provisions for Processing Personal Data in Healthcare Act - specific rules for handling medical data in healthcare settings
Wet op de Geneesmiddelenvoorziening: Medicines Supply Act - regulations regarding medication prescriptions and pharmaceutical care
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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