Afspraak? Bel 035 – 524 75 15.

Application form

On your invoice all treatments are specified, including all codes and tariffs as established by the NZa. This invoice may be sent to your health insurance company which will pay for the treatments according your insurance.

Before you fill in the application form, we would like to ask you First to agree to our terms of payment. These are: paying cash or by Pin, directly after treatment. No credit cards accepted

Do you agree to our terms of payment?: *

Yes

No

You can fill in and send the following application form:

Details

Gender: *

Male

Female

Christian name(s): *

Surname and initials: *

Zip code: *

City: *

Date of birth: *

BSN / Sofinummer (SSN): *

By law we need your BSN/Sofinummer in combination with your client information.

ID: *

Passport

Drivers Licence

Identity Card

ID number: *

Mobile number (SMS Service):

We would like to have your mobile number, so we can, if you wish, remind you by sms of your appointment.

Private telephone:

Work telephone:

We would like to have your telephone numbers so we can contact in you in case of an annulation or absence of one of our dental carers.

Email address: *

Address: *

Preference

Preference of time and day:

We will comply with your preference if possible

I would like an appointment as soon as possible:

Yes

No

I would like to be reminded of my appointment by SMS: *

Yes

No

Our clinic provides you with an SMS service, but you are at all times responsible for appearing at your appointment.

I would like to be reminded by email for an online check-up appointment: *

Yes

No

Our clinic will remind you of your check-up by post or email. You can indicate if you would like to be reminded of your check-up appointment by email. Via this service you can determine when you would like to have your appointment.

I would like to park behind the clinic: *

Yes

No

For our clients we have four parking spaces. When you have a appointment with us you are free to use them.

General health

When was your last visit to the dentist:

Are there any details concerning your health:

Yes

No

What are these details concerning your health:

Name GP/specialist:

Telephone GP/specialist:

How did you find Tandzorg?:

If you have any questions or remarks please not e them below:

You cannot become a patient at Tandzorg.nl. You will have to look for another clinic.

Questions marked with * are required.

Tandzorgbaarn.nl
Heemskerklaan 21
3742 AK Baarn
tel: 035 - 524 75 15
fax: 035 - 524 78 70
info@tandzorgbaarn.nl

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