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Medical patient intake form

In this form you can ask questions about medical content, request treatment, and grant the required permissions for this. Based on a number of questions and choices, we guide you online to an (possibly online) appointment with one of our gynaecologists.

Do you prefer to make your appointment by phone? That is also possible, call 073 - 7200 993 and choose option 1 (outpatient clinic).

Or ask your general question via the website

This intake form consists of six parts:

  • Personal information
  • Your reference to Karmenta
  • Your complaints and/or medical questions
  • Register as a patient
  • Financial information (reimbursement and health insurance)
  • Make an appointment

You can leave open questions that you do not want or cannot answer. Only the personal data on the first page and some permissions are mandatory to fill in. 

All links (for explanation and additional information) in this form open in a new tab of your browser. So you can always return to the tab with this form to complete it further.

Privacy and security personal data

An e-mail to info@karmenta.nl or via the reaction form, or the inquiry form, is not very suitable for sharing medical data. If you wish, you can share medical information in this form. Please keep it short. Your information is sent encrypted and stored securely. Read more about the security of your personal data in Karmenta's privacy-statement.

Note (1): This form contains a number of mandatory fields, recognizable by: (*). Please enter these fields correctly.


The reference to Karmenta

A referral from your general practitioner (or another medical specialist) is always required in order for your treatment at Karmenta to be covered by your health insurance policy. You can also visit Karmenta without a referral, but then you always have to pay for the treatment yourself.

Your reference:




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We can easily find your referral and data and the Zorgdomein number in our electronic patient file. If necessary, enter the ZD number in the comments at the end of this form.

You have a reference to Karmenta

That's handy! Your GP will almost always refer you to Karmenta via Zorgdomein, which means that we have all your data, including your referral letter, in our electronic patient file, and that you can now simply make an appointment. In principle (there are some exceptions) your treatment will now also be eligible for reimbursement by your health insurance.

If your GP does not refer to Karmenta via Zorgdomein, you will receive the referral as a letter from the GP. Then take that letter of referral to Karmenta on your first visit to our clinic. Or make sure we have it before your first visit. When making the appointment you will be registered as a new patient in the electronic patient file. At the counter for your first appointment, your referral letter will then be scanned and added to your file.

Your medical specialist referres you to Karmenta

Usually doctors from another healthcare institution or a medical specialist from another hospital do not refer via Zorgdomein, but by means of a referral letter. Usually this is sent to Karmenta via the secure Zorgmail and often (part of) your patient file is already attached there. Sometimes you will also receive the referral letter yourself.

You will be added as a new patient in Karmenta's electronic patient record. For this we need information from you, which you can fill in this form.

In principle (there are some exceptions) your treatment will now also be eligible for reimbursement by your health insurance.

If you received the referral as a letter, take that referral letter with you to Karmenta on your first visit to our clinic. Or make sure we have it before your first visit. When making the appointment you will be registered as a new patient in the electronic patient file. At the counter for your first appointment, your referral letter will be scanned and added to your file.

You have referral to another hospital or healtcare provider

But would you rather be treated at Karmenta? For example, because you can contact Karmenta faster, or because you have a preference for one of Karmenta's medical specialists.

Ask your GP (or other doctor who refers you to Karmenta) for a specific referral to Karmenta, as this is required for your treatment to be covered by your health insurer. If your GP does not (yet) know Karmenta, he/she can always contact us to inquire whether we are the right clinic for your complaints.

You have no reference to Karmenta

That's no problem! You are also welcome at Karmenta without a referral. But your treatment cannot be reimbursed by your health insurance without a referral and you will therefore have to pay for it yourself. Below you can read more about this and you can give permission for this.

We will now also have to add you as a new patient in the electronic patient file. For this we need information from you, which you can fill in this form.

We would now like to receive any information about your medical history from you, and if you would like to provide us with the details of your GP, we can inform them about your treatment at Karmenta. But if you don't want to, you don't have to. You pay for your treatment yourself, so you now have quite a lot to say about it yourself.


Your medical complaints:

Your question or complaint (medical content)

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Your gynecological question or complaint

You always discuss your gynecological question or complaint with the (female) gynecologist herself in Karmenta's consultation room. A video call consultation is sometimes also possible. More time is taken for you than in the hospital, so that we can also talk about your specific situation and the person behind the patient. This is important to us so that we can determine the best treatment for you together. So prepare your conversation well by, for example, writing down your questions at home, or by bringing someone along who can listen in. Of course we also discuss the intended result. But also the risks and possible complications. We will also check whether you have understood everything and possibly provide you with more information to make a good decision. If possible we make an (usually internal) ultrasound and sometimes we also do the treatment right away, if you want that of course.

Your urological question or complaint

You always discuss your urological questions or complaints with the urologist in Karmenta's consultation room. A video call consultation is sometimes also possible. More time is taken for you than in the hospital, so that we can also pay attention to your specific situation and the person behind the patient. This is important to us so that we can determine the best treatment for you together. So prepare your conversation well by, for example, writing down your questions at home, or by bringing someone along who can listen in. Of course we also discuss the intended result. But also the risks and possible complications. We will also check whether you have understood everything and possibly provide you with more information to make a good decision. If possible we make an (sometimes internal) ultrasound and sometimes we also do the treatment right away, if you want that of course.

Your question of complaint relating the menopause

You always discuss your questions or complaints about the menopause in Karmenta's consultation room with the (female) gynaecologist herself. A video call consultation is sometimes also possible. More time is taken for you than in the hospital, so that we can also talk about your specific situation and the person behind the patient. We think this is important in order to determine the best treatment for you together. So prepare your conversation well by, for example, writing down your questions at home, or by bringing someone along who can listen in. There is a form on the website with which you can already map out the menopausal complaints. We will then add this to your file, so that the gynecologist can see it before you come to the consultation. The gynecologist focuses mainly on the physical side of the menopause.

Karmenta also works with menopause consultants. Their treatment often also focuses on coaching and lifestyle. If you wish, we can of course refer you to this and possibly also discuss your specific situation (multi-disciplinary).

More information:

  • Karmenta's Menopause Consultation Hour
  • Menopausal complaints form (Greene scale).

Your question about the vaccination againts the Human Papiloma Virus (HPV)

HPV stands for Human Papillomavirus (HPV). In total, there are more than 100 HPV types. Some of these are high-risk HPV types. These can cause cancer. There are also low-risk HPV types. These can cause genital warts, among other things. Karmenta is one of the few clinics in the Netherlands that offers HPV vaccination against nine types of the HPV virus.

You can discuss your questions about HPV and the HPV vaccination with the urologist (men) or gynecologist (women). And in our clinic you can also be vaccinated. This is not always insured care, so you usually have to pay for the vaccination and treatment yourself.

MORE INFORMATION:

  • Website SamenTegenHPV.nl
  • Vaccinate against HPV.
  • Answers to the frequently asked questions about HPV. (shortly)

Your question about weight loss using medication

Sometimes it is important for the success of your treatment that you lose weight first. We can help you with this with medication and often also with the guidance of a dietician. We prescribe the medication with a prescription that you can get at the pharmacy, such as the Ceres Service Pharmacy in Heesch  (which has the medicine in stock). The treatment is usually covered by your health insurer, but the medication is not. You have to pay that yourself. Treatment by the dietician is usually covered by the reimbursement of your health insurer.

MORE INFORMATION:

  • Losing weight with medication.
  • Website HelpBijAfvallen.nl

Your question about the Mona Lisa Touch® laser treatment

The Mona Lisa Touch treatment is a laser treatment for the long-term recovery of vaginal dryness and vulvar pain. It provides long-term improvement in symptoms often related to vaginal atrophy and/or lichen sclerosus. At Karmenta we have a lot of experience with this treatment. The Mona Lisa Treatment is usually not covered by the reimbursement of your health insurer, you have to pay for the treatment yourself.

MORE INFORMATION:

  • Mona Lisa Touch treatment.

Your question about the Urolon™ behandeling

Urinary complaints and stress incontinence can be caused by a urethra that no longer closes properly, causing you to lose urine unintentionally. Urolon™ is a treatment in which a resorbable substance is injected around the urethra, so that the urethra is supported and closes properly again. The innovative Urolon treatment can in many cases prevent more serious surgery.

MORE INFORMATION:

  • More information about the Urolon™ treatment.
  • Website Product Information Urolon, Urinary Loss and Stress Incontinence
  • Website "Conquer your incontinence"

Your question about Karmenta's fertility treatments

If getting pregnant does not happen automatically, or if it takes much longer than expected, it is often a problem for you as a woman and of course also for you as a couple. Fertility (fertility) depends on many factors and understanding their interrelationships is often complex. Karmenta's gynecologists have a lot of experience in the field of fertility. They are pragmatic medical specialists who take the time to explain it clearly and clearly to you.

MORE INFORMATION:

  • Fertility
  • Doesn't getting pregnant come naturally?

Your question about a cervix smear at your own request

<Information to be filled in shortly>

MORE INFORMATION:

  • Website Evalyn® Brush

Pelvic physiotherapy

Karmenta works together with a pelvic physiotherapist. This means that we can treat complaints of the pelvic floor by both the gynecologist and the pelvic physiotherapist and that your treatment is coordinated. So you can only make an appointment with the pelvic physiotherapist if you are also a patient at Karmenta.There is multidisciplinary consultation about the patients and this allows us to determine the best treatment for your complaints together with you.

The pelvic physiotherapist works independently and autonomously

Although there is a lot of collaboration, the pelvic physiotherapist formally works as an independent healthcare provider. As a patient you have a treatment agreement with her and you will also receive an invoice from the pelvic physiotherapist, which you can submit to your supplementary insurance, if you have one, for reimbursement. You will therefore not receive a bill from Karmenta for pelvic physiotherapy, but you will for specialist medical care (the care product, DBC). You can make an appointment with a pelvic physiotherapist with Karmenta, you are also usually registered as a patient in the EPD of Karmenta and the pelvic physiotherapist.

More information

Voor een zorgvuldige en veilige behandeling ontvangen we graag informatie over je gezondheid, medische voorgeschiedenis en welke medicatie je gebruikt. 

Current medication overview (amo)

If you use medication, we would like to receive your current medication overview (AMO). You can request this from your pharmacy and upload it in the form below. You can also give it to us via a photo, a PDF or on paper at your first appointment. We'll add it to your patient record. You can also email your AMO to polikliniek@karmenta.nl. Please clearly state your name and date of birth.

Additional documents, referral letter, medical history

Do you have a referral letter or (your own notes about) your medical history that you would like to share with the medical specialist? Please add it below. We'll add it to your patient record. You can also email the information to polikliniek@karmenta.nl. Please clearly state your name and date of birth.

The reimbursement of your treatment

Much of Karmenta's specialist medical care is covered by your health insurance policy. But how exactly that compensation works depends on your policy conditions and is sometimes quite complicated. Karmenta does not have a contract with all health insurers. And, just like in a hospital, the statutory deductible deductible applies to insured care.

You will be fully reimbursed for the care bill in the following cases (with the exception of the deductible):

  • If you have a Refund Policy (Restitution Policy)
  • If you have a combination policy with reimbursement for specialist medical care
  • If you have a In-kind policy from a health insurer with which Karmenta has a contract (currently: DSW Zorgverzekeraar and Zilveren Kruis)


In the following cases you will have to pay part of the costs yourself:

  • If you have a In-kind policy with a health insurer with which Karmenta does not have a contract.
  • If you have a refund policy or combination policy that applies maximum reimbursements in the policy conditions
  • If your deductible has not yet been fully used
  • If, in consultation with the gynaecologist or urologist, you opt for a treatment that is not covered by a health insurer
  • With a number of additional products and treatments

Leniency arrangement (discount on your bill)

You can request leniency at Karmenta. The leniency scheme includes a discount on the care bill of up to 20%.

In the following cases you will have to pay all costs yourself:

  • If you do not have a referral from a general practitioner (or other medical specialist) to Karmenta
  • If you do not have health insurance from a Dutch health insurer
  • If you choose one of the uninsured treatments yourself (the rates for uninsured care apply)
  • For a number of treatments that are excluded from reimbursement by the health insurance
  • With a number of additional products and treatments

Read more about the rates of the insured healthcare products and the rates of the uninsured healthcare products here.

Read more about how the reimbursements work and how this differs per health insurer and per health insurance policy.

Do you have questions about this? Always ask this before your first appointment with the medical specialist. By telephone on 073 - 7200 993 (option 2) or by e-mail address: Zorgadministratie@Karmenta.nl

Your question or complaint (medical content)

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Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

Basisverzekering: Natura-polis

 

The reimbursement of your treatment

Much of Karmenta's specialist medical care is covered by your health insurance policy. But how exactly that compensation works depends on your policy conditions and is sometimes quite complicated. Karmenta does not have a contract with all health insurers. And, just like in a hospital, the statutory deductible deductible applies to insured care.

You will be fully reimbursed for the care bill in the following cases (with the exception of the deductible):

  • If you have a Refund Policy (Restitution Policy)
  • If you have a combination policy with reimbursement for specialist medical care
  • If you have a In-kind policy from a health insurer with which Karmenta has a contract (currently: DSW Zorgverzekeraar and Zilveren Kruis)


In the following cases you will have to pay part of the costs yourself:

  • If you have a In-kind policy with a health insurer with which Karmenta does not have a contract.
  • If you have a refund policy or combination policy that applies maximum reimbursements in the policy conditions
  • If your deductible has not yet been fully used
  • If, in consultation with the gynaecologist or urologist, you opt for a treatment that is not covered by a health insurer
  • With a number of additional products and treatments

Leniency arrangement (discount on your bill)

You can request leniency at Karmenta. The leniency scheme includes a discount on the care bill of up to 20%.

In the following cases you will have to pay all costs yourself:

  • If you do not have a referral from a general practitioner (or other medical specialist) to Karmenta
  • If you do not have health insurance from a Dutch health insurer
  • If you choose one of the uninsured treatments yourself (the rates for uninsured care apply)
  • For a number of treatments that are excluded from reimbursement by the health insurance
  • With a number of additional products and treatments

Read more about the rates of the insured healthcare products and the rates of the uninsured healthcare products here.

Read more about how the reimbursements work and how this differs per health insurer and per health insurance policy.

Do you have questions about this? Always ask this before your first appointment with the medical specialist. By telephone on 073 - 7200 993 (option 2) or by e-mail address: Zorgadministratie@Karmenta.nl

Authorization for any own costs

We think it is important that you understand how the reimbursement of treatment at Karmenta works in your case. After all, everyone's financial situation is different, so you have to think about it yourself. With Karmenta's leniency scheme, we also treat everyone financially fairly and the scheme is correct within the legal possibilities. We are happy to help you if you have any questions about this. Follow the links with explanation above or call Karmenta's care administration. And give us your permission:


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We think it is important that you understand how the reimbursement of Karmenta's care is reimbursed by your health insurance and what that means for you, because every health insurance policy is different. We are happy to explain it to you and often we can also provide an estimate in advance of any personal contribution. Call Karmenta for this and choose option 2: care administration.

Fine, thank you. It is sometimes quite complicated. We think it is important that the conversation in the consultation room is as much as possible about you and your health and as little as possible about money.

MANAGEMENT

If you have an administrator, you are obliged to notify us. We will probably need to get permission from your administrator for the costs before you start treatment.


Make an appointment

Would you like to make an appointment during consultation hours? Please call us in the morning between 9:00 and 11:00. Our telephone number is 073 - 7200 993 (option 1). You can also send an email, the email address is: Polikliniek@Karmenta.nl.



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Spreek/behandelkamer in Heesch

Spreek/behandelkamer in Heesch

De medisch specialiste en behandelaren werken op verschillende dagen op beide locaties van Karmenta.

Maakt de locatie je niet zoveel uit, dan zijn we wat flexibeler om je in te plannen in een van de spreekuren.


Finally...

We hope, of course, that you will feel comfortable, heard and at ease with Karmenta. We wish you a pleasant consultation and of course a good treatment. Give us your opinion with the comment form. Also read more about Karmenta's complaints procedure and the privacy statement.

We’re in the middle of Brabant and will welcome you with open arms

And coffee in the waiting room! You’ll find us in the middle of Brabant, not far from ‘s-Hertogenbosch and Eindhoven. A 10 minute drive from the A2, right next to a square with tons of free parking space.

Medisch Centrum Schijndel

Visiting Address

Telephone : +31-(0)73 - 7200 993
Fax : +31-(0)73 - 7200 908
e-mail : This email address is being protected from spambots. You need JavaScript enabled to view it. 

Opening Times

  • Work days :

    08:30 - 17:30 uur

  • Lunch
    12:30 - 13:00 uur

Karmenta can be reached over the phone on all work days from 08:30 - 17:00