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Home
Praktijk
Huisregels
House rules
Inschrijven
Sign up
Team
Veelgestelde vragen
Contact & Openingstijden
Contact & Opening hours
Medical intake child
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Home
Medical intake child
Name
*
First name
Last name
Email
*
Phone
*
Date of birth
*
Day
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1
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Year
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1920
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
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