Register as patient

This page is currently not available. If you want to register at our clinic please send an email to info@tandartspraktijk-utrecht.nl with your preferred contact data and we will contact you for making the first appointment. Please bring your identification with you when you’re visiting us for the first time.

    Personal data

    First name (required)

    Insertion

    Surname (required)

    Gender
    MaleFemale

    Date of birth (required)

    Burgerservicenummer (BSN) (required)

     

    Address data

    Street - Housenumber (required)

    Postal code (required)

    Place of residence (required)

     

    Contact data

    Phonenumber (required)

    Your e-mail (required)

     

    Insurance data

    Insurance company (required)

    UZOVI code insurance (required)

    Polis- of relationnumber (required)

    When was your last dentist visit?

    Remarks / important information