If you wish to submit an application for inspection, copy, correction or destruction of medical data at our general practice, you can use the application form below.
You can print, fill in and sign the application form.
We request you to bring the application form to the practice yourself along with your proof of identity so we can verify your identity.
Since compiling your copy may take several days and will take place after approval of your application it is not possible to wait for your copy at the practice.
If your application can be fulfilled, a copy of the requested data will be sent to you by post.
Note that the general practice is not liable for mistakes in mail delivery. If you prefer to collect the copy in person (or by an authorized representative) at the practice, you can indicate this on the form.