+49 30 5436324
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
High blood pressureLow blood pressureAngina pectorisArtificial heart valveHeart attackHeart defectArrhythmias
StrokeThrombosisVaricose veinsCirculatory disorder
Frequent nosebleedsCoagulation disorder (also in relatives)Postoperative bleedingBruises even without injury or after light contact
Hepatitis AHepatitis BHepatitis CCirrhosis of the liverJaundice
Requires dialysisPyelonephritisGlomerulonephritisRenal failure
Stomach / intestinal disease
Respiratory / pulmonary diseases
TuberculosisAsthmaSleep apneaSnoringChronic obstructive bronchitisPulmonary emphysema
Skeletal system / bone disease
OsteoporosisRheumatismAthrosisFibromyalgiaArtificial jointsMuscle diseases
Diabetes mellitus type 1Diabetes mellitus type 2Thyroid disease
Hay feverPainkillerFoodLatexAntibioticsMetalsIodineChlorides (e.g. Chlorix CHX)
Aids, HIVCancerOrgan TransplantRadiation, chemotherapy
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
Abnormalities in the mouth
Temperature sensitive teethPosition change of the teethGum bleedingFrequently breathe through the mouthOrthodontic treatment takes place
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!
For children, adolescents and adults. For patients with health insurance and private patients
© 2023 Zahnarztpraxis KreynitsMarzahner Chaussee 197, 12681 Berlin
Tel: +49 030 5436324E-Mail: firstname.lastname@example.org