Registration

You can submit your online registration here.

After registration you will recieve an confirmation with further information. If you have not recieved this confirmation by e-mail within 5 working days, then please contact the administration office at info@healthcare-academy.nl. In case of questions, please feel free to contact us.


 

REGISTRATION FORM

Title education / lecture

(Start) date 

Company / practice name

Salutation  Mr Mrs. Drs. Dr.

Initials and first name

Insertion

Surname

Date of birth

Place of birth

Address

Zip code

Residence

Country

Email address

Please fill out correctly because of the automated processing of Your registration

Telephone

Telephone Mobile

Please enter the phone number where we can reach You in case of emergencies on a day of classes.

Profession/Education

Professional Association

Amount in euro’s

I will transfer this amount to account 16.25.57.965 in the name of Healthcare-Academy Den Hoek, located in De Bilt, The Netherlands, quoting the invoice number.

IBAN NL93RABO0162557965 BIC RABONL2U

I agree to the Payment and cancellation policies  Yes No

Read here the conditions of payment and cancellation.

I agree to receive information by HealthCare Academy Den Hoek (You only need to fill out this box, if You do not already recieve our information automatically) Yes No

I am aware of this training through

Date

Signature

Captcha:

 

Healthcare-Academy Den Hoek ~ Bisschopsweg 2 ~ 3732 HW De Bilt (Nederland) ~ T:+31 (0)633688491 E: info@healthcare-academy.nl

 

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