Register as a patient at a Dental Clinics dental practice

Already a patient at one of our practices?

Are you already a patient at one of our Dental Clinics practices and want to register at another Dental Clinics practice, for example because of a move? Then click on the button below!

Switching

Register below as a patient at the practice of your choice. We will then contact you (by phone) to schedule an intake. Required velden are red and have a * symbol.

URL

This field is for validation purposes and should not be changed.

Dental Clinics practice*

Your personal data

How would you prefer to be addressed?*

As a man

As a woman

If neither

Name*

First name Surname

Email address*

Phone number*

Country*

Address*

Postal code House number + Addition

Street (will be filled in automatically) Location (will be filled in automatically)

Address*

Street + house number Location Postal code

Date of birth*

DD/MM/YYYY

Citizen service number (BSN).*

Example: 123456782.

Citizen service number (BSN).

Example: 123456782.

Additional family members

This field is hidden when viewing the form

Number of additional family members

Additional family members

Name	Date of birth	Actions

No additional Family Members have been added yet, please add them below.

Do you have any questions or comments?

Question/Comment (optional)

Do you have a specific treatment in mind, such as teeth whitening, invisible braces or veneers? Let us know below.

How did you hear about us?*

Other, namely*

What is first and last name of the aandrager?*

What is the email address of the person who nominated you for the action?*

What is the date of birth of the person who nominated you for the action?

CAPTCHA

Sign up within 2 minutes

Already a patient at one of our practices?

Your personal data

Additional family members

Do you have any questions or comments?