Register location Haarlem - Tandent - Kliniek van Tandheelkunde

Would you like to become a patient at Tandent Location Haarlem?

We are still accepting clients in Haarlem with reservations. If interested, please fill out the registration form and we will contact you as soon as possible.

Registration form location Haarlem

Fill out the form below or contact us.

Personal data

Last name

Initials

First name

Birthdate

Gender

Man Woman

BSN / Social security number

Address details

Streetname and house number

Addition

Postal code

Residence

Contact details

Home phone number

Work phone number

Mobile

Email address

Insurance data

If you are visiting the practice for the first time, please always bring your insurance card.

Name of your insurer

Policy number

Insurance start date

Date of your last dental visit

What are your dental requirements

Important data / Notes

We only use personal data you provide to give you the best possible service. See also our privacy statement. By pressing send you agree to this.