Patient Fields marked * are required.
Last name * First name * Date of birth (DD.MM.YYYY) * Email Street, house number * Postcode * Town / city * Phone (home) Mobile phone Occupation Employer Phone (work)
Policyholder (insured person) I am the policyholder myself (patient and insured person are the same) Last name * First name * Date of birth (DD.MM.YYYY) * Phone (home) Street, house number Postcode Town / city
Health insurance Type of insurance * Statutory (public) Private Supplementary insurance
Name of insurer * Town Branch Insurance number
Family doctor (GP) Name, town What is the reason for this dental visit? (multiple answers possible)
Check-up Toothache Bleeding gums Advice on dentures, crowns or bridges Jaw joint problems Advice on implants Professional teeth whitening Advice on replacing amalgam fillings
Other How did you hear about us? X-rays Approximate date of your last X-ray What was last X-rayed?
Our modern X-ray equipment keeps the radiation dose as low as possible. Please note that anaesthesia can impair your reactions and your ability to drive. Please inform us immediately of any changes to the information above.
Consent to photo and video documentation Voluntary – your decision has no effect on your treatment.
Signature – health questionnaire By signing, I confirm that I have answered the questions to the best of my knowledge.
Signature of patient or legal guardian * Please sign here with your finger Clear
Appointment reminders (recall) I agree to take part in the appointment reminder system (recall) of the practice Zahnärztliche Gemeinschaftspraxis Doctor-medic stom. (RO) Radu Hotinceanu & Doctor-medic stom. (RO) Lorelai Hotinceanu. Please contact me:
by phone by email by post
(nothing selected = no reminders)
Professional teeth cleaning Important notes about treatment in our practice Please note that, for the sake of your health, we do not use controversial amalgam. Among other things we use biocompatible cement fillings, all-ceramic inlays or gold inlays.
If you have pain or problems outside your appointment, we offer special times for this. Please call us beforehand to arrange an appointment.
Because we plan sufficient time for your treatment, we ask you to cancel appointments at least 24 hours in advance. Such a cancellation is free of charge. If you miss a longer appointment (30 minutes or more) or cancel it at short notice, a fee of approx. 100.00 euros may be charged.
Signature (I have read these notes) * Please sign here with your finger Clear
Special Care – for anxious patients Please close your eyes, calmly imagine the following question, then mark your feeling on the scale without thinking further: How do you feel at the thought of going to the dentist tomorrow to have a tooth treated?
Billing via ZA (optional) So that we can concentrate fully on your treatment, we work with ZA Zahnärztliche Abrechnungsgesellschaft Düsseldorf AG for invoicing. For this we need your consent.
Consent is voluntary. Your treatment does not depend on it and you will have no disadvantage if you say no.
💳 Without consent, you pay for private services and co-payments at our practice directly after the treatment: in cash or by card.
Please complete the fields marked in red.
