A+ Dental – Dental Practice at Belsenplatz Registration form · EN

Registration form

Dear patient, a warm welcome to our practice. To treat you with the lowest possible risk we need, alongside your personal details, some information about your general health. All information is covered by medical confidentiality and treated in strict confidence.

Patient details Please complete in block capitals
Surname
First name
Date of birth
Street and house number
Postcode / town
Phone
E-Mail
Occupation
Employer
GP
Insured person and insurance details only complete if different from the above
Insured person
Date of birth
Street and house number
Postcode / town
Name of insurer
Supplementary dental insurance
YESNO
Your visit
How did you hear about us?
Internet Recommended by Other
What brings you to us today?
Which dental practice did you attend before?
I am interested in
Implants Crowns / veneers Professional cleaning Teeth whitening Periodontitis treatment Other
A+ Dental – Dental Practice at Belsenplatz Please turn over · Page 1 / 2
A+ Dental – Dental Practice at Belsenplatz Registration form · EN

General medical history

Do you take medication regularly?YESNO
Bisphosphonates Blood-thinning medication Other
Are there any health risks? If yes, which?YESNO
Have you ever had circulatory problems or other reactions after an anaesthetic?YESNO
Do you have any allergies?YESNO
Latex allergy Antibiotic (if yes, to which and how did you react?)
Do you have, or have you had, any of the following?
Blood clotting disordersYESNO
Infectious diseasesYESNO
Cardiovascular diseaseYESNO
StrokeYESNO
DiabetesYESNO
Thyroid disorderYESNO
AsthmaYESNO
Lung diseaseYESNO
Kidney disease or abnormalitiesYESNO
RheumatismYESNO
GlaucomaYESNO
Seizure disorder (epilepsy)YESNO
Tumour / cancerYESNO
Do you suffer from depression?YESNO
HIV infection Hepatitis B Hepatitis C Heart valve defect Heart surgery Other
How is your blood pressure?lownormalhighnot known
Have you had radiotherapy or chemotherapy?YESNO
Other conditions (which?)YESNO
Do you smoke? If yes, how many cigarettes a day?YESNO
Women: are you pregnant? (If yes, which week?)UNSUREYESNO
Do you often have headaches or tension in the jaw or face?YESNO
Are you anxious about dental treatment?YESNO
I have read and understood this information. By signing, I confirm that my answers are complete and correct. I consent to my personal data (Art. 9 GDPR) being processed for the purposes necessary for my dental treatment and, where required, passed on to processors, doctors, health insurers and similar parties. I agree to being contacted by SMS or email.
If you do not attend the appointment reserved for you, or do not cancel it in good time (24 hours in advance), we reserve the right to charge a missed-appointment fee of € 88.
Düsseldorf, date
Signature · for minors, parent or guardian
A+ Dental · Cheruskerstraße 111 · 40545 Düsseldorf · 0211 570 025 · www.aplus-dental.de Page 2 / 2