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05. Medium Medical Contact Center

We make it easy

Register as a patient

Through this form you can register as a patient at Fonkelzorg International. It is very easy.

Registration form international employees

"*" indicates required fields

First name*

Initials*

Surname*

Date of birth*

DD slash MM slash YYYY

Gender*

Address*

Postal code*

Phone number*

Email address*

BSN Number*

Verzekeraar

AON Polisnummer

Proof of identity*

Identity card number*

LSP consent*

May your medical records be shared in case of emergency? For more information see https://www.volgjezorg.nl/en

Agreed*

I am familiar with the medical disclaimer for international patients and agree to register as an international patient.

Name

This field is for validation purposes and should be left unchanged.

Fonkelzorg International biedt huisartsenzorg speciaal voor internationale patiënten. Met zorg in eigen taal, ruimte voor nieuwe patiënten en persoonlijke aandacht maken we het verschil.

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