Register

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BSN-nummer*

Please enter a number from 9 to 9.

BSN-nr bestaat uit 9 cijfers, geen punten en komma’s

Citizens Service Number / Burger Service Nummer (BSN: 9 digits)*

Do you have a Dutch passport or driver’s license? You’ll find the BSN there.

Phone number 1*

A phone number is required in case of emergencies.

Contact person

Please fill in the first name and surname of contact person

Relationship to contact person

(e.g. father, sister, friend, neighbour, etc.):

Phone number contact person

Name of health insurance company

Health insurance number

How many children would you like to register?*

Surname – 1st child*

Initial(s) – 1st child*

First name – 1st child*

Date of birth – 1st child*

BSN number – 1st child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 1st child

Health insurance number – 1st child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

Surname – 2nd child*

Infix – 2nd child*

Initial(s) – 2nd child*

First name – 2nd child*

Date of birth – 2nd child*

BSN-Number – 2nd child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 2nd child

Health insurance number – 2nd child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

Surname – 3rd child*

Infix – 3rd child*

Initial(s) – 3rd child*

First name – 3rd child*

Date of birth – 3rd child*

Health insurance number – 3rd child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 3rd child

Health insurance number – 3rd child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

Surname – 4th child*

Infix – 4th child*

Initial(s) – 4th child*

First name – 4th child*

Date of birth – 4th child*

BSN number – 4th child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 4th child

Health insurance number – 4th child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

Surname – 5th child*

Infix – 5th child*

Initial(s) – 5th child*

First name – 5th child*

Date of birth – 5th child*

BSN number – 5th child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 5th child

Health insurance number – 5th child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

E-mailadresEmail address

Surname – 6th child*

Infix – 6th child*

Initial(s) – 6th child*

First name – 6th child*

Date of birth – 6th child*

BSN-Number – 6th child*

In case this child is covered by the health insurance of the parent(s)/guardian(s):

Name health insurance – 6th child

Health insurance number – 6th child

If applicable: the name and contact details of the other parent/guardian, besides yourself:

Are you between 12 and 16 years old?

If so, your parents/guardians need your permission to access your medical records. If you wish to give (or withdraw) permission, you can arrange this yourself at the SAG health center. Please come by and bring a valid ID. Our assistants will help you with the registration.

Previous general practitioner (GP)

Location previous GP*

Please remember to inform your previous GP that you are deregistering.

What is the name of your (new) pharmacy?*

Are you looking for a new pharmacy? Some SAG health centers have a pharmacy on site.

Registration application date*

With this form, you apply for registration. We will check if we can approve your application. You will receive notification regarding this. You are only registered once your application has been approved. Above, please enter the date on which you submit this form.

Make sure you have read important information, before you register or visit the doctor:

Register at one health care center only
(not more than one)!

Online registration form

Personal details

Health insurance

Family

1st child

2nd child

3rd child

4th child

5th child

6th child

Consent questions

Previous general practitioner (GP)

Other

Sectie-einde

Register

Make sure you have read important information, before you register or visit the doctor:

Register at one health care center only(not more than one)!

Online registration form

Personal details

Health insurance

Family

1st child

2nd child

3rd child

4th child

5th child

6th child

Consent questions

Previous general practitioner (GP)

Other

Sectie-einde

Register at one health care center only
(not more than one)!