to enrol inschrijven

To enrol

How nice that you want to become a patient with us. To make registration easier, you can already fill in your details. After receipt, we will contact you to schedule an initial intake appointment. During this first intake interview you can inform us of any complaints and/or wishes. During this visit you will also complete a health questionnaire. If you are taking medication, please bring your medication list with you. A set of X-rays will also be taken so that we can form a complete picture of your mouth. Don’t forget to take your health insurance card and identification with you.

    To enrol

    First Name*

    Last Name*

    Sex*

    ManWoman

    Date of Birth*

    Street and house number*

    Postal code*

    Residence*

    Phone number*

    E-mail:

    BSN number:

    Questions and/or remarks:

    Select an option:

    Add additional people?

    First Name:

    Last Name:

    Sex:

    ManWoman

    Date of Birth:

    BSN number:

    First Name:

    Last Name:

    Sex:

    ManWoman

    Date of birth:

    BSN number: