Online registration form Human

Due to busy times, we are currently unable to schedule patients

Due to busy and vacation season, we are having a patient stop for new patients The waiting list is currently full, so we will first offer those patients the opportunity to schedule an appointment.

The information that you send us via this form provides us with the necessary information for your consultation and for financial processing. Click here for our privacy statement.

By sending the registration form you agree to the general terms and conditions of the Holistic practice Den Hoek. Click here to read and / or print the general terms and conditions.

If you prefer to send your registration form by e-mail, click here.

Be aware:

Only fill in the form if you have already made an appointment via our assistants.

Fill in all required fields [*] and don’t forget to tick that you agree with the terms and conditions and tick the checkbox next to the text ‘I’m not a robot’.

Personal information

First and last name *

Phone number *

E-mail *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Appointment

Do you already have an appointment? *

Yes, on what date?
No, do you prefer a specific day? The assistant will contact you to schedule an appointment.

Information about your treatment

Date of birth

BSN number

Have you been referred? if so through whom?

Description of your complaints

What did the treatment consist of?

Previous treatment (blood tests, scans, etc.)

The General Terms and Conditions and the Privacy Statement of Holistic practice Den Hoek *

I hereby declare that I agree with the General Terms and Conditions and the Privacy Statement of Holistic practice Den Hoek

Name

Online registration form Human