Registration form

Become a new patient? Fill in the registration form

Thank you for your confidence to become our next new patiënt at Whitesmile. Many patients found their way to our practice.Be aware that by doing so we will take time and effort to customize the oral healthcare you need.This will lead to the following costs.
  • C010 medical anamnese 26,75
  • C012 dental intake 126,72
  • X21 OPT  X-Ray 84,48

Registration form

Firstname *
Birthdate *
E-mail *
Phone *
Lastname *
Sex *
Address *
Zip code *

New patient

If you wish to become a patient in our practice, there are some things I would like to bring to your attention.

In our practice, we strive for quality. The most important thing is your oral care at home. Without good oral hygiene by yourself, gum and jaw bone inflammation and of course tooth decay (cavities) will occur.
For this reason, we ask our patients to make a maximum effort concerning oral hygiene at home. Without this, we can’t guarantee high quality.
Of course, we will advise and guide you in this matter.

To let our contact run smoothly and efficiently we would like to draw your attention to the “practice rules”.

  • Check-ups are carried out in consultation with the dentist once or twice a year.
  • Following this, treatment appointments are made.
  • We aim to make an appointment for your next check-up immediately.
  • You are responsible for your appointment. If you are unable to keep your appointment, please cancel at least 24 hours in advance on working days (or leave a message on our answering machine). Otherwise, we are forced to charge for the scheduled time.

The dental rates are set by the Dutch Health Care Authority (NZa). Health insurance companies refer to the document with the dental rates as the policy rule Dental Care of the Dutch Health Care Authority.
In my practice, I work with an intake consultation for new patients, for which I plan plenty of time. This way we get the fullest possible picture of the patient, the mouth, and the wishes of each individual. Therefore you can count on the following costs.

Actions

We will contact you as soon as we have received the attached questionnaire.

If there is room for new patients, we can schedule you for an intake consultation. We may have to put you on a waiting list. If this is the case, you will be informed about this upon receipt of your registration form. As soon as there is room for new patients, we will contact you to make an intake appointment. To register as a new patient, we request that you complete a registration form. You can do this via this link. 

To obtain the form you can send an email to info@whitesmile.nl with the subject “registration form”. Of course you can also request a registration form by telephone on (040) – 2544544.

Don’t forget to let your previous dentist know about your switch, cancel your scheduled appointments and ask for your dental information to be sent to us.

We request that patients who have not been remediated should take into account that the treatments must be paid in cash until remediation.

Purpose of the practice

Our goal is to offer good dental care in all its facets, in which the human side of the patient is not forgotten. Trust, expertise and mutual respect are central, with the entire team committed to providing you, the patient, with the best possible information and proper treatment.

In our practice we strive for quality. The most important thing is your oral care at home. Without good oral hygiene by yourself, gum and jaw bone infections and of course also tooth decay (cavities) arise. We will of course advise and guide you in this.

Registration procedure

We request that you register yourself via the website via registration. After registration we will contact you and make an appointment for an intake interview. You will then receive a questionnaire from us that we would like to receive back via email before you have the intake appointment with us. Don’t forget to inform your previous dentist of your switch, cancel your scheduled appointments and request that your dental data be sent to us.

In my practice I work with an intake consultation with new patients, for which ample time is planned. This way we get the most complete possible picture of the patient, the mouth and the wishes of each individual. Therefore, you can count on the following costs.

Operation
Code
PRICE
* depending on the case and the time spent, code C002, C001 or C012 will be charged. The costs are a minimum of €26,75 and a maximum of €126,72. Provided you have taken out additional dental insurance, these costs are in most cases reimbursed by your health insurer. We advise you to check this with your health insurer. A discussion of the treatment plan or budgets can follow from the intake consultation, costs will be charged for this depending on the time spent.
Intake consultation
C001
€ 53,50*
Consultation, not being a periodic check
C002
€ 26,75*
Extensive research for the benefit of the integrated treatment plan
C012
€ 126,72
Additional medical history after (written) routine questions
C010
€ 26,75
Make and assess jaw overview photo
X21
€ 84,48
Take and review small x-rays (if necessary)
X10
€ 19,71/each
Tartar per unit of 5 min. (as needed)
M03
€ 15,78
Oral hygiene instruction or nutritional advice per unit of 5 min.
M01
€ 15,78

The dental rates are set by the Dutch Healthcare Authority (NZa).

We ask patients who have not been rehabilitated to bear in mind that the treatments must be paid in cash until remediation takes place.

We will contact you as soon as we receive the attached questionnaire.

We will contact you as soon as we receive the attached questionnaire.

If we have room for new patients, we may schedule you for an intake consultation. We can put you on a waiting list. If this is the case, you will be informed after receipt of your registration form. As soon as there is room for new patients, we will contact you to make an intake appointment. To register as a new patient, please fill in a registration form. You can do this via this page. To obtain the form, please send an email to info@whitesmile.nl with the subject “registration form”. Of course, you can also request a registration form by phone at (040) – 2544544.

Please remember to inform your previous dentist about your change, cancel your scheduled appointments and ask for your dental records to be sent to us.

We request that non-cleared patients take into account that until the treatment has been cleaned up, all payments should be made in cash.

Best regards,

Dentist R. Strijkert