Request form screening Tuberculosis – eFormulieren GGD Hollands Noorden

Request screening Tuberculosis (Consumption)

Use this form to ask for a screening on Tuberculosis (Consumption). If you don’t get a confirmation in jour e-mail, please contact us via 088-01 00 546 (we are available during week-days from 08.30-16.30 o’clock, Wednesday until 12.00 o’clock).

Name(Vereist)
Voornaam Achternaam
V-number of bsn-number(Vereist)
Date of Birth(Vereist)
DD slash MM slash JJJJ
Gender(Vereist)
- Male
- Female
- I don’t want to answer
- Other
Adress(Vereist)
Straat + huisnummer Stad Postcode
Phone number(Vereist)
E-mail Adress(Vereist)
Nationality(Vereist)
When did you arrive in the Netherlands?(Vereist)
DD slash MM slash JJJJ
Do you have a fit of coughing?(Vereist)
- Yes
- No
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Phone
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