Emergency

receptie@aldente-tce.nl

+31 (0)40 253 36 83

Register

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Register

You are very welcome at our practice!
Please fill in the form below as completely as possible and we will contact you within 24 hours.

Personal data

First name *

Initials *

Last name *

Sex: *
ManWomanotherwise

Please leave this field empty.

Date of birth (dd-mm-yyyy) *

BSN (Citizen Service Number) *

Contact details

E-mail *

Phone number *

Street name *

House number *

Postcode *

Residence *

Other questions

When was the last time you visited a dentist? *

Who was the previous dentist? *

When were x-rays last taken? *

Would you like to register multiple people?

Personal data

First name *

Initials *

Last name*

Sex: *
ManWomanotherwise

Date of birth (dd-mm-yyyy) *

BSN (Citizen Service Number) *

Other questions

When was the last time this person visited a dentist? *

Who was the previous dentist? *

When were x-rays last taken? *

Your comments:

I agree to the storage and processing of my data by this website. See also our privacy statement

* = required field

Please note: if you want to register several people at the same time: please first fill in your own personal details and then click on the 'Add person +' button

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