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

Fill in your details below. We will then contact you (by phone). Please have your citizen service number (BSN) ready. Velden with an asterisk (*) are mandatory.

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 City of Postal code

Date of birth*

DD/MM/YYYY

Citizen service number (BSN).*

Example: 123456782.

Citizen service number (BSN).

Example: 123456782.

Additional family members

Adding additional family members?

Yes

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.

Do you have any questions or comments?

Question/Comment (optional)

How did you hear about us?*

Other, namely*

CAPTCHA

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

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Already a patient at one of our practices?

Your personal data

Additional family members

Do you have any questions or comments?