Follow the steps to successfully complete the application form.

1. Press the ‘Get Form’ button to access the application form and open it in your browser or preferred document editor.
2. Begin by filling out the personal information section. Provide the name of the insured person, their date of birth, and current address, including the postcode and city or town.
3. Next, enter the telephone number and customer number. This information is crucial for identification and communication purposes.
4. In the medical certificate section, indicate whether you are applying for IVF or ICSI by ticking the appropriate box.
5. Provide a detailed indication or explanation for your request. This may include medical background or the reason for seeking treatment.
6. If you have undergone any previous fertility treatment, please describe it in the provided space, including the medications used and the supplier.
7. Tick any specialist procedures that were previously used for your IVF/ICSI treatment, such as MESA, PESA, TESE, GIFT, PGD, PGS, Assisted Hatching, or Egg Donation.
8. Specify if any part of the IVF/ICSI treatment is being carried out outside the Netherlands. If applicable, note the location.
9. Detail which aspects of the treatment are provided in the Netherlands and which are abroad to ensure clarity regarding your care.
10. Fill in the name of the organization providing the treatment and the city, town, and country where it is located.
11. List the name of the attending doctor and ensure the referral doctor's signature is included along with their stamp.
12. In the self-declaration section, tick the appropriate box for the number of attempts and provide the expected start date for the next attempt.
13. Specify the age at the commencement of the next attempt and indicate which phase of treatment you are in.
14. Finally, ensure that all fields are completed in full and that you have signed the document before submission.
15. Once all sections are accurately filled out, you can save your changes, download the form, print it for your records, or share it as needed.

Complete your application for IVF/ICSI treatment online today to take the next step towards your fertility journey.