All fields marked with * must be filled in.
Please only fill out the registration form after making an appointment.
For appointment requests / arrangements, please call us: 0511/ 123 75 00
Date of birth*
Place of birth*
Telephone during the day
Telephone in the evening
Date of birth
Place of birth
Health insurance or insurance
Are you entitled to the public allowance? Service?
Are you a private patient insured according to the basic rate?
For members of the statutory funds:
Compulsory insuranceVoluntary member
What is your main concern for me?
Does your gums sometimes bleed?
Is your gums withdrawing?
Do you wear orthopaedic shoe inserts?
Have you already been acupunctured?
Do you have back problems?
Do you suffer from respiratory failure?
Do you suffer from daytime sleepiness?
Have or have had health problems with (please tick the applicable):
Circulation, blood pressure
too hightoo low
Bleeding tendency, bleeding disorders
Hay fever, asthma
Allergies, intolerance to
Infectious diseases (TBC, HIV, hepatitis)
Liver disease, jaundice
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)?
Have there been any incidents in previous dental treatments?
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:
You've finally made it!
Thank you again for answering all the questions so carefully. If filling in the sheet has any problems, do not hesitate to contact us. That's what we're here for you.
I agree that my details from the contact form will be collected and processed to answer my request. The data will be deleted after your request has been processed.