Registration form for residents of COA locations

Please fill in the form below to register for dental care at your COA location. After we receive your registration, we will contact you to schedule an appointment.

Personal details

First name *

Last name *

Date of birth *

Gender (optional)

Staying at a COA location

COA location *

V-number / registration number (optional)

Contact details

Phone number *

Email address (optional)

Preferred language

Health insurance

We use this information solely to invoice the treatment.

Insurance provider (optional)

Insurance card / policy number (optional)

Photo of your insurance card (optional)

Upload a clear photo of your insurance card (front and/or back). Allowed: JPG, PNG (max. 8 MB). If you don't have your insurance card at hand, you may leave this field empty.

Dental information

Reason for registration / complaint *

Previous dental problems (optional)

Allergies or medication use (optional)

Additional notes (optional, e.g. interpreter needed, support needed, fear of the dentist)

Name of parent/guardian, if the resident is a minor (optional)

I give permission for Mobiele TandZorg Nederland to process this information, solely for the purpose of my dental treatment. *