• 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 and 1078. Registration for patients outside the region (ie a zip code other than the one indicated) is not possible.

    First name

    Family name

    Date of birth

    Telephone number



    Postal code

    Place of residence

    Place of birth



    Previous doctor

    Residence previous doctor


    BSN number

    Insurance company

    Health insurance number

    I give permission to request my information from my current doctor

    Do you give permission to the practice to exchange your most important medical data electronically (via the LSP) with other healthcare providers?
      Yes   No

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