Register

  • To subscribe to our practice as a new patient you can fill in the form below. On your first visit we will ask for your insurance card and a copy of your ID.

  • The range of our working area contains the following postal codes: 1072, 1073, 1074, 1078 and 1079. When you live or move to an area outside these postal codes you can still be our patient but we won’t be able to make home visits to your address.

First name

Family name

Date of birth

Telephone number

E-mail

Address

Postal code

Place of residence

Place of birth

Gender

Profession

Previous doctor

Residence previous doctor

BSN number

Insurance company

Health insurance number

I give permission to request my information from my current doctor