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



    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

    Unusual reaction

    Abnormalities in the mouth

    Family doctor


    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!