Online aanvraag | MediCentraPlus

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You can submit a new registration using this form. We will receive the information directly in the portal, after which the registration can be followed up.

Your first name *

Your last name *

Your phone number *

Your email address *

Type of registration *

Description *

Consent for registration and data sharing *

I (the individual concerned) or their legal representative has been informed and expressly consents to this application and to the sharing of the provided personal data, including health data, for the purposes described below.

*For this application, the provided contact details, administrative data, and health data will be shared with an orthopedic specialist. This data will be used to process the application, to contact the individual concerned, to submit the application for review to a qualified doctor or medical specialist, and to coordinate the process administratively. As necessary, the relevant data will be shared with the doctor, medical specialist, or other healthcare provider conducting the assessment or treatment of the application. The data will only be processed for the purpose for which it was provided and in accordance with applicable privacy legislation.

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