Sign-up for care

All information that we register is protected by medical confidentiality.
Please come to the clinic within two weeks with a proof of identity (passport/ ID/ driving licence (no copies) to validate your registration.
You are welcome to do this from Monday to Friday, between 08:00 and 12:30 and between 13:00 - 17:00. No appointment necessary.

Your name

Surname / Last name *

Initials *

First name *

Gender *

Marital status *

Maiden name

(in case married)

Date of birth *

Dag

Maand

Jaar

Contact information

Current address *

(street & number)

Zip code *

City *

Phone

Mobile phone

Email address *

Insurance & identification

Insurance company *

(Please type 'not yet' if you do not have an insurance)

Insurance number *

(Please type 'not yet' if you do not have a client number)

UZOVI code

(The identification code of your insurance company)

BSN-number *

(A BSN (burgerservicenummer) is the citizen service number, a unique registration number for everyone who lives in the Netherlands)

Passport / ID card / Drivers licence *

Medical history

Do you have a previous GP in The Netherlands? *

Previous General Practitioner

Name previous GP *

City previous GP *

I authorise the release of my medical records at my current general practitioner *

Yes

Are there specific medical conditions we should know about upfront?

Do you use medication at this time?

Pharmacy

Do you have a pharmacy in Utrecht? *

Name current pharmacy

Which pharmacy would you like to go to?

In case of an emergency

Who should we contact?

Phone

Family

Do you have another member of your family already registered in this health centre? *

Relative already registered

Name relative *

Date of birth relative *

Dag

Maand

Jaar

Extra family members

Would you like to register another family member? *

Another family member (1)

Surname / Last name family member *

Initials family member *

First name family member *

Gender family member *

Marital status family member *

Maiden name family member

Date of birth family member *

Dag

Maand

Jaar

Insurance & identification family member (1)

Insurance company *

(Please type 'not yet' if you do not have an insurance)

Insurance number *

(Please type 'not yet' if you do not have a client number)

UZOVI code

(The identification code of your insurance company)

Passport / ID card / Drivers licence *

BSN-number family member *

Extra family members

Would you like to register another family member? (2)

Another family member (2)

Surname / Last name family member (2) *

Initials family member (2) *

First name family member (2) *

Gender family member (2) *

Marital status family member (2) *

Maiden name family member (2)

Date of birth family member (2) *

Dag

Maand

Jaar

Insurance & identification family member (2)

Insurance company *

(Please type 'not yet' if you do not have an insurance)

Insurance number *

(Please type 'not yet' if you do not have a client number)

UZOVI code

(The identification code of your insurance company)

Passport / ID card / Drivers licence *

BSN-number family member (2) *

Extra family members

Would you like to register another family member? (3)

Another family member (3)

Surname / Last name family member (3) *

Initials family member (3) *

First name family member (3) *

Gender family member (3) *

Marital status family member (3) *

Maiden name family member (3) *

Date of birth family member (3) *

Dag

Maand

Jaar

Insurance & identification family member (3)

Insurance company *

(Please type 'not yet' if you do not have an insurance)

Insurance number *

(Please type 'not yet' if you do not have a client number)

UZOVI code

(The identification code of your insurance company)

Passport / ID card / Drivers licence *

BSN-number family member (3) *