Patient registration

Here you can fill out the anamese form in advance and save valuable time.

Your private data will be transmitted securely encrypted via an SSL connection.

The fields marked with (*) are mandatory fields.

    To the person

    First name (*)

    Last name (*)

    Birthday (*)

    Birthplace (*)

    Health insurance company private insurance fund (*)

    Occupation (*)

    Employer

    Is there additional insurance? (*)

    Contact us

    Address (*)

    Postcode (*)

    Location (*)

    Phone (private) (*)

    Phone (mobile) (*)

    Email address (*)

    Health issues

    Do you have a splint? (For example sleeping or ginding splint) (*)

    Do you have allergies, such as penicillin? (*)

    Do you have asthma? (*)

    Do you have a thyroid overfunction or underfunction? (*)

    Do you have lung disease? (*)

    Do you have a heart condition? (*)

    Do you have high blood pressure? (*)

    Do you have low blood pressure? (*)

    Do you have blood clotting disorders? (*)

    Do you have infections such as hepatitis, TB, HIV? (*)

    Do you have diabetes? (*)

    Have eye diseases, e.g. green star (*)
    Are you taking medication? (*)

    Are you a smoker? (*)

    Tooth-to-mouth situation

    Do you have bleeding gums or gum decline? (*)

    Do you have noises in the jaw joint, for example, when yawning or chewing? (*)

    Do you have a head or neck pain? (*)

    Do you wear a denture? (*)

    Have you been given orthodontic treatment? (*)

    Do you use other oral care products besides the toothbrush? (*)

    When and with whom was the last time you were x-rayed dental? (*)

    What particular concern will lead you into our practice?

    Do you wish to be reminded of a screening every six months? (*) Are you happy with the position, color, shape of your teeth, briefly with your smile? (*)

    Are you interested in intensive prevention of tooth decay and gum decline? (*)

    Do you have any comments or requests?

    How did you become aware of us or who can we thank for the recommendation?

    Patient ID

    In the event that you are unable to take advantage of a reserved treatment time, we therefore ask you to cancel in good time (that is, if possible 2 days in advance). You are doing us and your fellow patients a great favour with this. If there is no appearance without prior rejection, we will no longer be able to give you fixed appointments for organisational reasons. Downtime can be calculated in accordance with Section 615 BGB 287 ZPO.
    We hope that you will feel comfortable in our practice and will be happy to answer any questions you may have.

    Please tick here before sending here:
    I have read and accepted the terms and conditions of practice.