Register

Bedankt voor uw interesse in onze praktijk! Wilt u zo vriendelijk zijn om uw oude tandartsdossier voor de eerste afspraak naar ons te verzenden? Zodra u voor een intake bij ons bent geweest en het klikt met de behandelaar, bent u officieel ingeschreven als patiënt. Wilt u een kind inschrijven onder de 16? Gebruik dan this form.

Salutation

First name

Surname

Date of birth

Address

City

Zip

Phone

Citizen Service Number (BSN)

Appeal

Doctor

Previous dentist

Preferred

How did you come to us?

When was your last dental visit?

How many times a year do you normally visit the dentist?

Are you afraid of the dentist?

How important are your teeth to you?

Are you satisfied with your teeth?

Does your gums bleed regularly while brushing and/or flossing / toothpicking?

Have you ever had gum treatment?*

Does periodontitis (chronically inflamed gums) run in your family?

Have you had cavities in the last 5 years?

Are there teeth or molars sensitive with eating, drinking, brushing and / or flossing?

Do you have a place where food often gets stuck between the teeth or molars?

Do you ever suffer from a jaw snap, clenching or crunching?

Has the position or shape of your teeth changed in the last 5 years?

Do you have little saliva or difficulty swallowing food?

Is there anything about your teeth or smile that you would like to change?

Do you currently have problems and / or complaints regarding your teeth?

Are you being treated by a doctor or medical specialist?

Are you allergic to something?

Have you had a heart attack?

Do you suffer from palpitations?

Are you being treated for high blood pressure?

Do you have chest pain with exertion and/or emotions?

Do you get short of breath when you lie flat?

Do you have a heart valve defect, artificial heart valve or artificial hip?

Do you have a congenital heart defect?

Do you have a pacemaker (ICD) or neurostimulator?

Have you ever passed out at a (dental)doctor?

Have you ever experienced hyperventilation?

Do you have an epilepsy diagnosis?

Have you ever had a cerebral hemorrhage or cerebral infarction (or TIA)?

Do you have lung complaints such as asthma, bronchitis or chronic cough?

Do you have diabetes?

Do you have anemia (anemia)?

Have you ever had prolonged bleeding after surgery?

Do you have hepatitis, jaundice, or any other liver disease?

Do you have kidney disease?

Do you have rheumatism and/or chronic joint problems?

Have you been irradiated because of a tumor in the head and/or neck area?

Are you being monitored by the Thrombosis service?

Do you use blood thinners?

Do you smoke?

Do you use alcohol?

Do you suffer from depression or depression?

Have you ever experienced a serious illness?

Do you have a disease that was not mentioned above?

Do you currently have an infectious disease?

Are you pregnant?

Are you breastfeeding?

Are you currently on medication?

Some patients have their financial or administrative affairs managed by an administrator or budget manager. If this applies to you, you can fill in the contact details below so that we can coordinate bills and appointments correctly.

Name of Administrator / Office

Telephone number/e-mail address administrator/office

Do you have a preference for a day and/or time to schedule a first appointment?

Confirm Email