Customer data:
Fields marked with * are mandatory fields.
First name and surname*
Street and house number*
Postcode and town*
Health insurance*
Is it a private health insurance policy? Yes No
Profession / Employer*
Date of birth*
E-mail*
Telephone*
Mobile
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Insured person or contact person for minors:
First name and surname
Street and house number
Postcode and city
Profession / Employer
Health insurance fund
Is it private health insurance? Yes No
Date of birth
e-mail
Telephone
Mobile
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Customer questions
Fields marked with * are mandatory fields.
Do you have supplementary dental insurance?* Yes No
Is there entitlement to aid? Yes No
If so, which ones?
What is the name of your dentist?
Where is your dentist based?
Have x-rays been taken in the last 6 months? Yes No
If so, where and when?
Have you already had an orthodontic consultation/treatment? Yes No
If so, where and when?
Have other family members had orthodontic treatment? Yes No
What bothers you most about misaligned teeth and jaws?
Is / was your thumb sucked? (only for children) Yes No
Is / was a dummy used? (only for children) Yes No
If so, for how long?
Do you grind or clench your teeth? Yes No
Were teeth or jaws injured in an accident? Yes No
Are there / have there been complaints of the temporomandibular joint, the masticatory muscles or frequent headaches? Yes No
Are there any chewing or swallowing difficulties? Yes No
Is individual prophylaxis / PZR carried out regularly? Yes No
Is it difficult to breathe through the nose or mouth? Yes No
Is there / was there a speech defect? Yes No
Have tonsils or adenoids been removed? Yes No
Are there any allergies? Yes No
If so, which ones?
Do you need regular medication? Yes No
If so, which ones?
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Do you have any of the following conditions?
Fields marked with * are mandatory fields.
Cardiovascular disorders* Yes No
Diabetis* Yes No
Asthma* Yes No
Blood clotting disorders* Yes No
Epilepsy* Yes No
HIV* Yes No
Tuberculosis* Yes No
Rheumatism* Yes No
Rheumatism in the family* Yes No
Other* Yes No
If so, which ones?
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How did you find out about us?
Dental recommendation Google Acquaintances / relatives Instagram Facebook Jameda Miscellaneous
Other:
With my signature I confirm the completeness and correctness of the information provided overleaf and above.
Place and date*
Signature (Signature by mouse, finger or digital pen)
Information on data protection according to EU_DSGV
Declaration of consent by the customer or their legal representative
I expressly consent to the storage of my personal data I my child's personal data. All information is subject to medical confidentiality in accordance with Section 203 of the German Criminal Code (StGB) - this information will be used for my treatment and for communication with my dentist. Our company regularly checks your creditworthiness when concluding contracts and, in certain cases where there is a legitimate interest, also for existing customers. For this purpose, we work together with Creditreform Boniversum GmbH, Hammfelddamm 13, 41460 Neuss, from whom we receive the necessary data. For this purpose, we transmit your name and contact details to Creditreform Boniversum GmbH. The information pursuant to Art. 14 of the EU GDPR on the data processing taking place at Creditreform Boniversum GmbH can be found here: https://www.boniversum.de/eu-dsgvo/informationen-nach-eu-dsgvo-fuer-verbraucher
Place and date*
Signature (Signature by mouse, finger or digital pen)
Note:
The agreed appointments are reserved exclusively for you. Please avoid cancelling and rescheduling appointments at short notice, and we will charge you privately for appointments that are not cancelled at least 24 hours in advance and that could be booked elsewhere - in accordance with §§ 615 [regulations of the service contract] and 280. para.1 [breach of contractual ancillary services] of the German Civil Code (BGB) - and will invoice you for the loss of fees. We are also authorised to charge members of the statutory health insurance scheme in accordance with the scale of fees for dentists (GOZ).
As a special service, we offer you a reminder of your appointments about 48 hours in advance. I hereby authorise my orthodontist to remind me of the above-mentioned point in the following way:
I do not wish to receive an appointment reminder By SMS By e-mail
E-mail for appointment reminder
Mobile number for SMS appointment reminder
Place and date*
Signature (Signature by mouse, finger or digital pen)
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