Register as a new patient dentist

Submitform dental care

By filling in the below form you can register to become a patient. Please fill in one form for each person.

Personal information:

Last name + Initials *

gender *

First name *

Birth date dd/mm/yyyy *


Street name + number *

ZIP code *

City *

Phonenumber home

Phonenumber at work

Phonenumber mobile

E-mail address *

Insurance information:

Name health care insurance *

Polisnumber *

Do you have any dental issues?

Other information that can be helpful for us


Please fill in the above combination *