Inschrijf formulier – engels

Because of many new registrations, we have to put you on a waiting list. This way we can assure you a high quality treatment. The waiting time is now approximately 5 month.


At your appointment we kindly ask you to give us your BurgerServiceNummer (BSN)

Please enter patient information. We will contact you in approximately 3 month.

First name:

Initials:

Last name:

Date of birth:

Gender:
MaleFemale


Name of your dentist:

City of your dentist:


Your contact information:

Street and housenumber:

Postal code:

City:

Phone number at home:

Mobile number parent:

Mobile number patient:

Email (letters and reminders):

Email patient (reminders):


Medical information:

Are there allergies known to you? (e.g. Nikkel, latex and plastic) YesNo

Are there any heart, blood or vessel abnormalities known to you? YesNo

Dit something ever hit your teeth?YesNo

Do you use any medication that we should know of? YesNo

If you answered any of the above with yes, or if there are other things we need to know, please explain below.
If you already made an appointment by phone, please write it also in the box.

Enter this code: captcha

Submit and send a copy to yourself



The first appointment costs approximatly 20,- euro.
Please cancel at least 24 hour in advance (you can also cancel by email).
If not cancelled in time, we will charge you 15,- euro.

Invisalign gecertificeerd sinds 2001

Branchecertificaat van de Nederlandse
Vereniging van Orthodontischen