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Contact --> Registration form

By completing the following form you can register at our practice.
Depending on the postal code of your address and on the workload of the practice at that moment, you will be registered with us.
Within a week after we receive the completed form, your will receive a confirmation. You will be registered with our practice only after you have received our confirmation.

Sending your personal data via this website will be at your own risk.

Surname: *
First name: *
Date of birth: ( day-month-year ) *
Street and house number: *
Postal code: *
Town: *
Telephone number 1: *
Telephone number 2:
Indication of the due date of birth : ( day-month-year )*

Have you previously been a client of our practice:

Yes
No
 
 

* Note: please complete all blocks, unless stated otherwise.