The Student Doctors

First name Enter your given names exactly the same as on your passport.

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Last name

Date of birth

Gender (optional)

Nationality

Postal code

House number

Street

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E-mail

Phone number International format (+31 6 12 34 56 78)

Health insurance provider

Health insurance policy number

Passport number

Dutch Citizen service number (BSN) (optional) 8/9 numbers no dots or spaces.

Photo of the back of your European Health Insurance Card (EHIC) (optional)

I hereby confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be used to facilitate my medical care and will be kept confidential as per the privacy policy of The Student Doctors.

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Please note that by submitting this form, you agree to receive relevant updates and communication from The Student Doctors.