Register Registration is only possible if you live in one of the following postal codes:2311, 2312, 2313, 2321, 2322, 2323, 2324We always make an appointment for an introductory conversation when you register as a new patient in our practice. You can prepare for this conversation with this handy checklist from Thuisarts.nl.Completed data will be deleted once processed. We store your data in our secure medical environment. PersonYou can register children under the age of 16 together with yourself if they reside at the same address. Inhabitants over 16 years old must fill out the form separately.First Name *Last Name *InitialsMaiden NameSurname at birth (if changed during marriage)GenderMaleFemaleDate of Birth *Day *Month *Year *Place of BirthIf outside the Netherlands, please indicate city and countryMarital StatusSingleMarriedCivil PartnershipDivorced after marriageDivorced after civil partnershipWidowed after marriageWidowed after civil partnershipAddress informationStreet name and number *Postal code *City *Contact informationEmail address *Phone Number *Name of health insurance company *Insurance policy number *Insurance policy start date *If you have recently switched to a different insurance policy, the start date is usually January 1st.BSN *Citizen Service Number (can be found on your Dutch driver's license and ID card)0 / 9Name of current General Practitioner/GP PracticeLocation of GP PracticeWhich pharmacy in Leiden would you like to register at? *U kunt op deze kaart een apotheek in de buurt vinden.Data transfer *I agree to the retrieval and exchange of my data with my current GP. Retrieving your medical records from your previous GP is necessary for providing medical care.Submit FormPlease do not fill in this field.