Registration form international Students

International students living in Leiden can register with our GP practice.

It is common practice in the Netherlands to be registered with a GP practice. This way, should a medical problem arise, you can make an appointment with us and will not have to search for a doctor first.
To register, please fill out the form below.

We aim to process your application within a few days. You will receive a confirmation as soon as the registration is complete.

URL
Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.
Personal data
Surname:
Initials:
First Name:
Date of birth:*
Day
Month
Year
Place of birth (country/city):
Sex:
- Male
- Female
Social Security number (BSN):
Profession/study:
Expected date of departure from Leiden
Dag
Maand
Jaar
Address in Holland
Street:*
Housenumber:*
Postal Code:*
City:*
Phone:*
E-mail:
Insurance details
If you visit the doctor for the first time, always take your insurance papers with you.
Insurance:
AON/EHIC:
Policy number:*
Starting date of insurance:
Dag
Maand
Jaar
Pharmacy:
Previous doctor:
Name of your previous family doctor:
Address (previous doctor):
Place (previous doctor):
Telephone (previous doctor):
Important information / Comments
E.g. medication, allergy, history, hypersensitivity, current illness, pregnancy, breastfeeding, etc.
Comments:

Registration form international Students

Personal data

Address in Holland

Insurance details

Previous doctor:

Important information / Comments