Registration form

Please only fill out the registration form after making an appointment.
For appointment requests / arrangements, please call us: 0511/ 123 75 00

appointment at*

First name*

Last name*

Date of birth*

Place of birth*

Street, No.*

Residence*

Telephone during the day

Telephone in the evening

Mobile phone

E‑mail

Profession

Employer

Name

Surname

Date of birth

Place of birth

Street, No.

Residence

Health insurance or insurance

Are you entitled to the public allowance? Service?

yesno

Are you a private patient insured according to the basic rate?

yesno

For members of the statutory funds:

Compulsory insuranceVoluntary member

What is your main concern for me?

Does your gums sometimes bleed?

yesno

Is your gums withdrawing?

yesno

Do you wear orthopaedic shoe inserts?

yesno

Have you already been acupunctured?

yesno

Do you have back problems?

yesno

Snoring?

yesno

Do you suffer from respiratory failure?

yesno

Do you suffer from daytime sleepiness?

yesno

Have or have had health problems with (please tick the applicable):

Heart

Pacemaker

Circulation, blood pressure

too hightoo low

Bleeding tendency, bleeding disorders

Hay fever, asthma

Allergies, intolerance to

Infectious diseases (TBC, HIV, hepatitis)

Liver disease, jaundice

Diabetes

Thyroid disease

Rheumatism

Other diseases

What disease do they take medication against all the time?

Who have provided you with dental care?

Who recommended you to us?

When was the last time you were given dental conceit?

Have you already been treated with orthodontics (tooth braces)?

yesno

Have there been any incidents in previous dental treatments?

yesno

I ask you, in your own interest, to inform us immediately of any change in your state of health.

For our patients: Please inform us immediately if you are pregnant!

As a special service, we offer you that we remind you of your precautionary and/or prophylaxis appointments:

yesno