To register at our practice please fill out the registration form below. You can only register at our practice if you live near us. In case of an emergency we need to be able to be with you on time. This means a 7 minute bike ride for our doctors. Postal codes 3511, 3512 and the new houses in the Central Station area are within that range.

Registration form

Please show your  ID card or passport to the assistant at the desk at your first visit.

Please fill out one registration form for each family member.

    Personal details



    First name*

    Last name*

    Maiden name

    Date of birth (day/month/year)*

    Place of birth*

    Marital status

    Profession/daily activities

    Have you been registered at GP Practice Mariahoek Before?

    General practitioner of your choice

    Address details


    House number*

    Postal code*


    Phone number*

    Email address*

    Insurance details

    BSN number*

    Insurance company

    Heath Insurance company

    Thick here If not a Dutch health insurance

    Client number

    New Pharmacy Utrecht*

    If not yet registered at a pharmacy than you need to register at one, alongside of your registration at our practice.

    Previous General practitioner

    Are there any other family members, registered at our practice living at this address?

    Please let your previous general practitioner know that you have registered with us and contact them to ask to send us your medical file. Because of patient privacy regulations we can not request your medical information ourselves. If you have a medical file in another language please contact our assistants to discuss adding it to your medical file with us.