Referral form

This page allows you to easily refer a patient to us for further treatment. We will ensure professional and careful follow-up and keep you informed of progress.

Please complete the referral form as completely as possible. We will contact the patient after receiving it.

Referral form

First name

Surname

Referrer's email address

Phone number

First name

Surname

Initials

Date of birth

Street name + House number

City

Postal code

Phone number

Patient's email address

Insurance name

Insurance registration number

Place

Select a sub-area

Select a sub-area*

Reason for referral

Which location would you like to refer to?

Locations

Privacy statement

I agree to the processing of my personal data according to the privacy statement*

Referral form

Referral form

Oude Rijn Tandartsen

Location Alphen aan den Rijn

Location Leiden

No long
waiting times

Free parking
next door

Easily accessible
by public transport

Many specialisms
under one roof

Opening hours Alphen aan den Rijn

Opening hours Leiden

Alphen aan den Rijn

Leiden

Information

Referral form

Referral form

Oude Rijn Tandartsen

Location Alphen aan den Rijn

Location Leiden

No long waiting times

Free parking next door

Easily accessible by public transport

Many specialisms under one roof

Opening hours Alphen aan den Rijn

Opening hours Leiden

Alphen aan den Rijn

Leiden

Information

No long
waiting times

Free parking
next door

Easily accessible
by public transport

Many specialisms
under one roof