Registration - Familymember

Step 1.
Choose who you would like to register.

Step 2.
Enter your personal details.

Step 3.
We will contact you by phone within two working days. We will then schedule an intake appointment together and briefly explain the registration process.

Step 4.
Attend your intake appointment. Please arrive 15 minutes early and bring your passport, ID card, or driving licence. If applicable, please also bring an up-to-date medication overview (AMO).

"(Required)" geeft vereiste velden aan

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More information about family registration

Please enter your family member’s details below. On the next page, you can indicate whether you would like to register another family member. When you click "Submit", your family member’s details will be sent to us. If you choose to register another family member, a new form will be displayed.
Dit veld is verborgen bij het bekijken van het formulier
Dit veld is verborgen bij het bekijken van het formulier
Dit veld is verborgen bij het bekijken van het formulier
Dit veld is verborgen bij het bekijken van het formulier
Dit veld is verborgen bij het bekijken van het formulier
DD slash MM slash JJJJ
Have you attended regular dental check-ups in recent years (at least once a year)?(Required)
Debt restructuring(Required)
Protective administration(Required)
Consent(Required)