English Registration form - Huisarts Gezondheidscentrum Brakkenstein

General practitioner Nijmegen
Registration form for foreign students

Bedankt voor uw bericht. Het is verzonden.

Er is een fout opgetreden bij het verzenden van uw bericht. Probeer het later opnieuw.

Surname *

Initials *

Gender *

Date of birth *

E-mailadres *

Telephone number *

Second phone number

Address and number *

Postalcode *

City *

BSN *

Insurance *

Passport or ID card *

Passport or ID card number *

Permission for data exchange with GP (hospital) in the evening or in the weekend? *

Yes

No

Previeus GP (in the Netherlands *

From with country are you coming? *

Important:

When do you leave the Netherlands? We will erase your file or on request we’ll email it to you. *

Thanks for your registration!