Rietwijkerstraat 52, 1059 XB Amsterdam

Registration

New client registration Dental Practice De Liefde

Are you looking for a dentist specialized in biological dentistry? Then you are welcome with us as a new client. You can register via the registration form beneath.

If you would like to schedule an intake with a non-biological dentist, you are most welcome at one of our other practices and we will be happy to refer you to Lassus Tandartsen (www.lassus.nl).

    Would you also like to register your partner?
    YesNo

    Would you also like to register your children?
    YesNo

    How many children do you want to register?
    123


    Gender
    ManVrouw


    Do you smoke?
    YesNo


    Gender
    MaleFemale


    Do you smoke?
    YesNo

    Child 1


    Gender
    MaleFemale


    Child 2


    Gender
    MaleFemale

    Child 3


    Gender
    MaleFemale