It is possible to register as a patient if you are living within a two kilometer radius of the practice. We need time to process your application. You can make an appointment two working days after completing this form.

    Personal data

    Gender

    Initials*

    First name*

    Last name*

    Maiden name

    Date of birth*

    Place of birth*

    Social security number*

    Marital status

    Profession

    Were you previously registered with the Trompenburg general practice in the past?

    Address data

    Street name*

    House number*

    Postal code*

    Place*

    Phone number*

    E-mail address*

    Insurance data

    Insurer*

    UZOVI number (4-digit number on your insurance card)

    Clientnumber*

    Name and address of last general practitioner

    Would you like to inform your previous general practitioner that you have switched to our practice and ask to forward your medical file?



    The practice is temporarily unable to accept new patients.

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