Register | Referred | LACH Dental Care

I have been referred

You have been referred by your own dentist or another healthcare provider and received a referral letter. We start with an intake consultation, which takes between 15 and 45 minutes depending on the referral.

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To schedule an appointment, please fill in your details. We will then contact you.

1. MY DETAILS

2. REVIEW

3. SUBMIT

My Details

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First name

Initials / middle name

Last name

Date of birth

Postal code

House number / addition

Street name

City

Phone number

Email address

Reason for referral

Referrer Details

Referrer name

Practice name

Dentist name

I consent to the referrer transferring information to LACH Dental Care and to LACH Dental Care obtaining information from my own dentist.

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Summary

My Details:

I have been referred

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My Details

Referrer Details

Are your details correct?

Summary

Do you have a question?
We’d love to hear from you.
hello@lachmondzorg.nl

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Contact

Have a question? We'd love to hear it.

Ask your question here.

I have been referred

Enter your details

My Details

Referrer Details

Are your details correct?

Summary

Do you have a question? We’d love to hear from you. hello@lachmondzorg.nl

Call me back

Contact

Have a question? We'd love to hear it.

Ask your question here.

Do you have a question?
We’d love to hear from you.
hello@lachmondzorg.nl