Changing your details

It is important that the hospital has the correct data of its patients. So we can quickly and adequately communicate with and about you.
You can make changes in your details using the form below.

Changing your details

Mr., Mrs. or Ms. *

Mr.

Mrs.

Ms.

Initials: *

Surname (Birth name): *

Married name:

Birth date (dd-mm-yyyy): *

Citizen Service Number:

Phone number: *

Below you can register your changed details. Just fill in the fields of which your information has changed!

Changed address and/or phone number

New address:

New zip code and residence:

New phone number:

Moving date:

Changed general practitioner

Name new general practitioner:

Address new general practitioner:

Zip code and residence new general practitioner:

Health insurance

New health insurance:

New health insurance number:

Start date new health insurance

Pharmacy

Name new pharmacy:

Address new pharmacy:

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