Registration

"*" indicates required fields

Please fill out the form below. At minimal the field marked with an asterisk (*).

After you submitted, you will receive an e-mail with further instructions. When you visit us, we ask you some extra information and we ask you to sign do make the registration complete.

Child

Gender*

Privat name*

Family name*

Date of birth*

Dutch personal number (BSN)

When you leave this empty, we will ask you to provide it to us later.

Does your child have a Dutch health insurance?*

Yes

Family Doctor's name

Family Doctor's city

Parent/caregiver

Gender

Mrs.

Mr.

Initials*

Family name*

Address*

Postal Code*

City*

Phone number mobile*

Email address*

Other

How did you reach us?

Other:

Tick the box below

Phone

This field is for validation purposes and should be left unchanged.

Do you have a question?

Feel free to contact us.

Mon.	08.30 tot 17.00 uur
Tue.	08.30 tot 17.00 uur
Wed.	08.30 tot 17.00 uur
Thu.	08.30 tot 17.00 uur
Fri.	08.30 tot 17.00 uur