How did you get involved in the practice?

Do you have a level of care (or disability)?

Do you have supplementary dental insurance?

In the interest of a complication-free treatment, we kindly ask you to mark all applicable details with a cross.

Heart / Circulatory disease

Vascular disease

Blood disease

Liver disease

Kidney disease

Stomach / intestinal disease

Respiratory / pulmonary diseases

Skeletal system / bone disease

Metabolic disease

Eye disease

Nerve Diseases

Allergies

Immunodeficiency

Pregnancy (If yes, which week of pregnancy)

Do you smoke? (If yes, how much a day?)

Regular medication (please provide medication list).

Unusual reaction to dental treatment measures

Abnormalities in the mouth

I confirm the accuracy of the above information

Clarification about data protection was provided.

Consent to appointment reminders via SMS and/or e-mail.
In order to avoid missed appointments, we would like to remind you of your appointment via SMS and / or e-mail using the Doctolib calendar system.

Dear patients, our practice is run with an ordering system. We ask you to cancel the appointment 24 hours in advance, otherwise we will charge you a cancellation fee according to § 615 BGB in the amount of € 30.00!