Application form guest dialysis

Holiday dialysis is only possible for the period from March 14, 2025 to October 25, 2025 at location Texel subject to availability.

To avoid disappointment, we advise you to wait to book your holiday accommodation until your dialysis request has been approved by us.

Application form guest dialysis

Location *

Sex *

Initials *

Name *

Street *

House number *

Postal Code *

City *

Country *

Phonenumber *

Mobile number

Email address *

Date of birth *

Citizen service number *

Name/Address/Tel. no. of your own dialysis centre *

Weeknumber(s) in which you wish to have dialysis *

Frequency *

Preferred days *

If applicable your insurance number

Family practice

Have you ever had dialysis at one of our locations? *

Extra comments