Salutation: Mr.Mrs. First name
Initials
Insertion
Last name
Date of birth
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Address Postal code + town / City Telephone number Mobile phone number E-mailaddress Back Next [cf7mls_step cf7mls_step-2 "" "" ""]
Add partner YesNo
Add children YesNo
Who brought you to us? Why did you choose our practice? Back Next [cf7mls_step cf7mls_step-3 "" "" ""]
I have read and agree to the general terms and conditions of Beekmans Tandartsen, including the cancellation and protection of personal data below:
Cancellation terms and conditions Appointments that are rescheduled or cancelled by the patient for whatever reason must be communicated to us at least 48 hours in advance during office hours, preferably by telephone. If you do not notify us in time, we will charge you for the cost of the lost time.
Protection of personal data I allow my personal data, images, results and/or models to be shared with third parties. These are colleagues, dental technicians, health insurers and government agencies. My data may also be used anonymously for research, publications, accreditations, lectures, own website and patient information.
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