Registration form for new patients (international students)

UHP - registration form for international students

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Salutation

Your initials

Your given name

Your surname

Street name and house number

Zip code

Place name

Your mobile telephone number

Your e-mail address

Your date of birth

Place of birth

Your Dutch social security number ("BSN")

Leave blank when unknown or not available

The name of the health insurance company

Insurance number

Upload a proof of your insurance

Do you have:

Dutch health insurance? Make a picture of the backside of the insurance card.
AON? Make a picture of the insurance certificate stating the expiry date of the certificate.
EHIC? Make a picture of the backside of the insurance card.

Upload a scan or photo of your health insurance card. Make sure that the insurance number and your name are clearly visible.

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Name of person to be notified in case of emergency

Telephone number of the person to be notified in case of emergency

Living situation

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