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From application to patient

To register as a patient in our practice, please complete the application form online. We will then process your application. We aim to send you a response within 5 working days.
Please ensure that all your old dental records are sent to us prior to the first appointment.
Once you have visited us for your first appointment, and there is a fit with the practitioner, you are officially registered as a patient.
If you experience severe pain symptoms before that moment, please contact either:
- your previous dentist,
- or, the Mondzorgpoli in Slotervaart hospital https://www.mondzorgpoli.nl/
  020 723 4848
- or, the Emergency Dental Clinic at OLVG East https://tandartsspoedpraktijk.nl/ 0900-8602
  These clinics can normally see you the same day.

NOTE: when we receive your data (application form and/or old file), but you do not schedule an intake appointment within 6 months, we deactivate your patient card.

Sign up form adult from 16 years old (for child see below)

Titel*
Name*
First name Last name
Date of birth*
Citizen service number (BSN)*
Address*
Address + house number City Zip code
Email*
Phone number*
Occupation
Family doctor*
Previous dentist*
How did you find us?
- Family / friends
- Internet
When was your last dentist visit?
- Less than a month
- 1-6 months
- 1-3 years
- Never
How often do you visit the dentist?
- More often than 2 times per year
- 2 times per year
- 1 time per year
- less then once per year
Are you afraid of the dentist?
- Anxious
- Little Anxious
- Not Anxious
Are you happy with your teeth?
- Very satisfied
- Satisfied
- Dissatisfied
How important are your teeth for you?
- Very important
- Important
- Not important
Do your gums often bleed while cleaning your teeth?
- Yes
- No
Have you ever been treated for gum disease?*
- Yes
- No
Namely
Does periodontitis occur in your family?*
- Yes
- No
Have you had any cavities within the last 5 years?*
- Yes
- No
Do you have sensitive teeth?*
- Yes
- No
Do you frequently get food caught in between your teeth?*
- Yes
- No
Do you have problems/questions regarding your teeth/gums/smile/mouth?
Do you have problems with your jaw joint?*
- Yes
- No
Have your teeth changed (form or position) in the last 5 years?*
- Yes
- No
Do you have little saliva or difficulty swallowing (food)?*
- Yes
- No
Is there anything about the appearance of your teeth that you would like to change?*
- Yes
- No
Namely
Are you being treated by a doctor or medical specialist?*
- Yes
- No
Are you allergic?*
- Yes
- No
Namely
Have you had a heart attack?*
- Yes
- No
When
Do you suffer from heart palpitations?*
- Yes
- No
Are you being treated for high blood pressure?*
- Yes
- No
For
- Top pressure
- Bottom pressure
Do you have chest pain during physical exertion and/or emotions?*
- Yes
- No
Are you short of breath when lying flat?*
- Yes
- No
Do you have a heart valve defect, an artificial heart valve or hip?*
- Yes
- No
Do you have a congenital heart defect?*
- Yes
- No
Do you have a pacemaker?*
- Yes
- No
Have you ever fainted at the doctor/dentist?*
- Yes
- No
Do you experience hyperventilation?*
- Yes
- No
Are you diagnosed with epilepsy?*
- Yes
- No
Have you ever had a stroke?*
- Yes
- No
If so, when
Do you have a lung disease such as asthma or bronchitis?*
- Yes
- No
Do you have diabetes?*
- Yes, Type I
- Yes, Type II
- No
Do you have anemia?*
- Yes
- No
Have you ever had a prolonged bleeding after surgery?*
- Yes
- No
Do you have hepatitis, jaundice or other liver disease?*
- Yes
- No
Do you suffer from kidney disease?*
- Yes
- No
Do you have rheumatoid arthritis and/or chronic joint problems?*
- Yes
- No
Are you irradiated because of a tumor in the neck and/or head?*
- Yes
- No
Are you being monitored for thrombosis?*
- Yes
- No
Do you use anticoagulants?*
- Yes
- No
Do you smoke?*
- Yes
- No
How many a day?
Do you use alcohol?*
- Yes
- No
How many a week?
Do you suffer from depression or dejection?*
- Yes
- No
Have you ever experienced a serious illness?*
- Yes
- No
Namely
Do you currently have an infectious disease?*
- Yes
- No
Namely
Do you have a disease not mentioned above?*
- Yes
- No
Namely
Are you pregnant?
- Yes
- No
Are you currently breastfeeding?
- Yes
- No
Do you currently use any medication?*
- Yes
- No
Namely
Do you have a preference for a day/time to make the first appointment?
Are there things that we can take into account? Or do you have any other questions?*
- Yes
- No
Namely
I confirm that:*
- I have read and agree to the house rules
- Florens Tandartsen stores and processes my information for dental for purpose
CAPTCHA

Sign up form child

Name*
First name Last name
Email*
Phone*
Date of birth*
Citizen service number (BSN)*
Family doctor*
Previous Dentist (if applicable)
Did your child have cavities in the past 5 years?*
- Yes
- No
Does you child have senstive teeth?*
- Yes
- No
Are there particularities regarding the change of the primary teeth?*
- Yes
- No
Namely
Is your child seeing an orthodontist?*
- Yes
- No
Did your child ever fall on the front teeth or chin?*
- Yes
- No
Are there other things regarding the teeth we can take into account?*
- Yes
- No
Namely
Is your child allergic?*
- Yes
- No
Namely
Did you breastfeed your child?*
- Yes
- No
Was your child born with heart failure?*
- Yes
- No
Is your child diagnosed with epilepsy?*
- Yes
- No
Does your child have a lung disease such as asthma or bronchitis?*
- Yes
- No
Is your child diabetic?*
- Type 1
- Type 2
- No
Does your child have anemia?*
- Yes
- No
Does your child have hepatitis or a liver disease?*
- Yes
- No
Does you child have a kidney disease?*
- Yes
- No
Does your child have problems eating or gastrointestinal complaints?*
- Yes
- No
Does your child experience behavioral problems? (such as anxiety or hyperactiveness)*
- Yes
- No
Namely
Is your child attending special education or medical daycare?*
- Yes
- No
Is your child using medication?*
- Yes
- No
Namely
I confirm that:*
- I have read and agree to the house rules
- Florens Tandartsen stores and processes my information for dental for purpose
I confirm that:*
- I have read and agree to the house rules
- Florens Tandartsen stores and processes my information for dental for purpose
CAPTCHA

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