Anamnesis form

Do you want to fill out the anamnesis form before your first treatment?

Because of the privacy law, I ask you to read the privacy statement and the treatment agreement. At the start of the first treatment I will ask you to sign it.

Law on privacy documents


Personal details

Consultation Doctor okay?
Consultation specialist okay?


Reason Contact



You hereby agree with the treatment and with the costs of the consultation of € 90.00 per hour. You can pay in cash or with pin. Using pin is desirable.
If you are unable to attend, you must call 24 hours in advance, otherwise we will be obliged to charge you for the costs.