Registratie Formulier

Belangrijke boodschap: het invullen van het registratieformulier betekent NIET dat u direct bij onze huisartsen wordt ingeschreven. Uw inschrijving is pas van kracht nadat wij contact met u hebben opgenomen en een eventuele intake hebben gedaan.

Your primary residence (home address)

Other family members

Family member #1
Family member #2
Family member #3
Family member #4
Family member #5

Registration & appointment

Booked appointment
Will you be bringing a referral letter with you?
(Necessary if you have an appointment with a specialist, are registered with a GP elsewhere and have Dutch insurance)
Please upload your referral letter, if any (as a scan, PDF or good photo with your phone).
Please indicate here if you are changing insurance provider, address, have a special request or would like to leave a comment.
Would you like to stay up-to-date and receive our quaterly newsletter?

By submitting this form, I/we understand and agree to the terms and conditions on the IHCH website and in the IHCH Code of Conduct. I/we also agree to be a registered patient(s) at the IHCH located at Jan van Nassaustraat 125, 2596BS The Hague

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