We make it easyRegister as a patientThrough this form you can register as a patient at Fonkelzorg International. It is very easy.Registration form international employees"*" indicates required fieldsFirst name*Initials*Surname*Date of birth* DD slash MM slash YYYY Gender*ManWomanOther / do not wish to sayAddress in the Netherlands*Postal code in the Netherlands*Phone number*Email address* BSN Number*Insurance companyAON Insurance numberProof of identity*Dutch passportDutch ID cardAlien documentForeign passportIdentity card number*LSP consent*YesNoMay your medical records be shared in case of emergency? For more information see https://www.volgjezorg.nl/enAgreed* I am familiar with the medical disclaimer for international patients and agree to register as an international patient.NameThis field is for validation purposes and should be left unchanged.
