Register

With the form below you can register as a patient of the Jan van Nassau Dental Center like more than 5,000 others. You must complete a separate form for each family member. We will of course treat your data confidentially.

"*" indicates required fields

Step 1 of 2

Gender*

Man

Woman

Name*

First Last

Date of birth*

Telephone*

Email*

Address*

Street adress + number City Zip code

Social security number*

Select your insurer*

When was the last time you went to the dentist?*

What else is important to know