New patients may call us to register or you may complete the form below.
Tel. 035 - 6233230
Monday to Thursday from 8.30-11.00 and 13.30-16.30
Friday from 8.30-11.00 and 13.00-15.30
Once we have received your application form we will contact you to make an appointment with the orthodontist. Kindly complete the application form as fully as possible. If you do not have a home phone please fill in your mobile number under “Telephone number” instead.
The question that asks whether you are a robot acts as a captcha to secure our website against spam. Please put “nee” (‘no’ in Dutch) in the box because of course you are not a robot, you are a person :).
Application form orthodontic practice
Questions with an * are compulsory