Application form Client

  • Name
  • Address
  • Phone number
  • E-mail address
  • Date of birth
  • Startdate treatment


For a good treatment it is necessary that I, as your treating homeopath, prepare a file. This is also a statutory duty imposed by the WGBO. Your file contains notes about your state of health and data about the examinations and treatments performed.

The file also contains information that is necessary for your treatment and which I, after your explicit permission, requested / can request from another healthcare provider.

We do our best to ensure your privacy. This means, among other things, that I:

  • handle your personal and medical data carefully,
  • ensure that unauthorized persons do not have access to your dataAs your treating homeopath, I have sole access to the data in your file.

I have a legal duty of confidentiality (professional secrecy).

The data from your file can also be used for the following purposes:

  • To inform other health care providers, for example if the treatment has been completed or with a referral to another therapist. This only happens with your explicit permission.
  • For use for observation, during my absence.
  • For the anonymised use during peer review.
  • A small part of the data from your file is used for the financial administration, so that my administrator or I can draw up an invoice.If I want to use your data for another reason, I will first inform you and ask your permission explicitly.

These data in the client file remain as required by law on the treatment agreement for 15 years.


You will find the information requested by the insurer on the healthcare note that you receive. You can then claim the invoice from your health insurer.

Your name, address and place of residence
your date of birth
the date of treatment
a brief description of the treatment, in this case homeopathic advice
the costs of the consultation


Leusden, date …………………….

M.S. du Floo, classic homeopath Client                                          Client