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PMC in Balans

Physiotherapy

PMC in Balans Zeeland

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Department	PMC in Balans Zeeland
Physiotherapy practice	PMC in Balans
First name of your child:
Your account	What is your relation to the child? Mother Father Guardian (male) Guardian (female) Grandmother Grandfather What is your birthdate? dd-mm-yyyy Your e-mail address: Is there someone else taking care of the child? Yes No What is his/her relation to the child? Mother Father Guardian (male) Guardian (female) Grandmother Grandfather What is his/her birthdate? dd-mm-yyyy If you want to create a separate account (with a separate password) for this person please fill in his/her e-mail address. When this field is left blank you will share a single account.
Child's e-mail address	If your child is 8 years or older and has their own email address, please enter this email address here. A personal account will then be created for your child, so that you and your child can log in with your own email address and password. You can leave this field blank if your child does not have their own email address or if you don’t want to create a separate account for your child.
Date of birth of the child	dd-mm-yyyy
Gender	Boy Girl Other I do not want to specify
Terms	I agree with the terms and conditions of KLIK Physiotherapy
Vragenlijsten kind	Mijn kind is 7 jaar of jonger Mijn kind is 8 jaar of ouder, en kan zelf vragenlijsten op de KLIK website invullen (eventueel met wat hulp). Mijn kind is 8 jaar of ouder, maar is niet in staat om zelf vragenlijsten in te vullen. De reden hiervoor is: verstandelijke beperking, eventuele toelichting: lichamelijke beperking, eventuele toelichting: meervoudig complex gehandicapt, eventuele toelichting: anders, namelijk (vul hiernaast in): Toelichting:
Date of next appointment with the practitioner:	I don't know the next appointment with the practitioner yet. dd-mm-yyyy What type of appointment is this?   Problemen in de bovenste helft van het lichaam Problemen in de onderste helft van het lichaam Problemen in de bovenste en onderste helft van het lichaam Ik weet het niet
Practitioner	Search practitioner: Bianca Reijnaars - van der Wal No search results