• Home »
  • Online Inschrijfformulier

Online registration form

Please take note: this form will not be sent digitally. After you completed this form you can print it or save it as a PDF. You will need to sign it and take it with you when you register. Your registration is complete when you show identification and insurance policy at your first visit in the health center.

Select your health center below or select a center on the map

Personal details

Insurance details

Permission questions


Do you give us permission to use your mobile phone number for our sms service?



Do you give us permission to use your email address for our email service?



Do you give the health center permission for making your medical information available through the LSP? If so, please visit LSP permission form.

Former GP


Do you give us permission to obtain your medical file from your former GP?


Other


Complete registration

After you completed this form you can print it or save it as a PDF and sign with your signature.

Children from 0 to 12 years:
Signed by only the parent(s)/guardian(s)
Children from 12 to 16 years:
Signed by both the parent(s)/guardian(s) and the child
Children over 16 years:
Signed by only the child

Please bring the completed form with your signature to the health center during your next visit. Also bring a valid insurance card/policy and identification (passport, ID-card or Dutch driver’s license).
Your registration is definite when you’ve handed in the form and showed your insurance card/policy and identification.