Intake Name cliënt: Voornaam Achternaam Mobile numberDamage date: Datumnotatie:MM slash DD slash JJJJ Sort incident:VerkeersongevalBedrijfsongevalDierenaansprakelijkheidAndersWhat happened?Was the ambulance there?Yes, they just checked on healthYes, they took client to hospitalNoWas the police there?YesNoWas the fire brigade there?YesNoHave had medical treatment? Nothing yet Family doctor practice First aid hospital Emergency room HAP Physiotherapist Employment situation Paid employment Entrepreneur without employees Entrepreneur without employees Social security benefi Tax non-compliant activities Others PositionBrief description of the dutiesMarital statusSingleMarriedRegistered partnershipDivorcedWidowedGeen titelEerste keuzeTweede keuzeDerde keuzeE-mailadres
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