Subscribe form AOFE Clinics

We will contact you soon after filling out this form below. Your subscription will be automated in the Electronic Patient File (EPD) of AOFE Clinics

Social Security Number (BSN) *
Initials
First name *
Insertion
Birth name *
Marital status *
Gender *
Nationality *
Date of birth *
Place of birth *
Country of birth *
Mobile number *
Phone number (private)
E-mail address *
Postal code *
Housenumber *
Housenumber addition
Street *
Residence *
Township / municipality *
Province
Contact person
Contact address
Contact mobile phone number
Name general practitioner *
Address GP *
Postal code GP *
Place GP *
AGB code GP
E-mail address GP *
Name health insurer *
Policy *
Policy number *
Health insurer contact person
Privacy statement *
Verification *