Registration

Do you live close by and do you want to be a patient in our practice, then you can:

  • Come by and fill in the registration-form at our practice and subsequently use your passport or ID-card to identify yourself
  • Fill in the online registration-form on this page and send it

The general practitioner will take your registration under review and will send you a reaction quickly. When we can register you as a patient of our practice you will receive confirmation from us via e-mail.

If you live outside our area of operations or if the practice temporarily can’t take on any new patients, it could be possible you’ll receive a rejection from us. If you don’t live close by, you can use this site to find a general practitioner in your area.

When you want to register more than one person, you will have to fill in a registration form for each individual person.

Only after receiving the registration form, a first appointment can be made.

  • WITH THIS FORM YOU WILL REGISTER YOURSELF AT GENERAL PRACTICE KONINGSLAAN. DALTONLAAN IS A DEPENDANCE FROM THE KONINGSLAAN. WHEN YOU MAKE AN APPOINTMENT YOU WILL BE ABLE TO CHOOSE AT WHICH ADDRESS YOU WOULD LIKE THE APPOINTMENT TO TAKE PLACE.
  • For example: von, le, etc.
  • Fill in when married
  • Please fill in the country plus city/village, etc.
  • Fill in a 10-digit Telephonenumber
  • Please fill in the name of your Health Insurance Company
  • Emergency Contact

    Who to call in case of an emergency in the Netherlands!
  • How can we reach your Emergency Contact
    How are you related to this person?
  • General Practitioner

  • Name
    Please fill in whether or not you agree that we transfer your medical records from your last GP to us
  • Pharmacy

  • Please fill in the name of your Pharmacy in the Netherlands
  • Sharing medical information and privacy

    In case of an emergency it can be helpful if an emergency doctor can look into your medical file. Herefor we have in the Netherlands the “Landelijk Schakelpunt (LSP)”. This is save and could help you in case of an emergency. For more information please go to: www.ikgeeftoestemming.nl.
    By agreeing here and sending this registration-form I am agreeing to the Privacy Statement and Regulations privacyverklaring of General Practice Koningslaan.
  • Children

  • SurnameInitial(s)First NameM/F/ODate of BirthSocial Security NumberHealth Insurance CompanyHealth Insurance Polis Number