Anamnesis Form Dental Office Smile To Win

Please fill out this form carefully, it serves our preparation for your treatment. Unless marked as optional, all fields must be completed. Of course, the information provided is subject to medical confidentiality. If individual questions or information do not apply to you, please note this briefly (e.g. with not applicable).

1. Personal Data


A. Patient data

  • Month
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
  • Day
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
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  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
  • Year
  • 1921
  • 1922
  • 1923
  • 1924
  • 1925
  • 1926
  • 1927
  • 1928
  • 1929
  • 1930
  • 1931
  • 1932
  • 1933
  • 1934
  • 1935
  • 1936
  • 1937
  • 1938
  • 1939
  • 1940
  • 1941
  • 1942
  • 1943
  • 1944
  • 1945
  • 1946
  • 1947
  • 1948
  • 1949
  • 1950
  • 1951
  • 1952
  • 1953
  • 1954
  • 1955
  • 1956
  • 1957
  • 1958
  • 1959
  • 1960
  • 1961
  • 1962
  • 1963
  • 1964
  • 1965
  • 1966
  • 1967
  • 1968
  • 1969
  • 1970
  • 1971
  • 1972
  • 1973
  • 1974
  • 1975
  • 1976
  • 1977
  • 1978
  • 1979
  • 1980
  • 1981
  • 1982
  • 1983
  • 1984
  • 1985
  • 1986
  • 1987
  • 1988
  • 1989
  • 1990
  • 1991
  • 1992
  • 1993
  • 1994
  • 1995
  • 1996
  • 1997
  • 1998
  • 1999
  • 2000
  • 2001
  • 2002
  • 2003
  • 2004
  • 2005
  • 2006
  • 2007
  • 2008
  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016
  • 2017
  • 2018
  • 2019
  • 2020
  • 2021
  • 2022
  • 2023
  • 2024
  • 2025
  • 2026
  • 2027
  • 2028
  • 2029
  • 2030
  • 2031
  • 2032
  • 2033
  • 2034
  • 2035
  • 2036
  • 2037
  • 2038
  • 2039
  • 2040
  • 2041

B. Caregiver data / invoice recipient

These fields under B are to be filled in only if the data differ from section A.

 


2. Health condition

Diseases and medications of all kinds can have an impact on dental treatment. Therefore, we ask you to carefully complete the following questions. Your medical history will be attached to your personal records and is, of course, subject to medical confidentiality.

 

For the protection of mother and child, we ask for immediate notification if pregnancy occurs during the treatment period!

If you know the contact details of your family doctor, please fill in below:

Please let us know if your health condition has changed.


3. Teeth and mouth condition


4. Do you have any special requests for your individual treatment planning?


5. Important notes on the treatment in our practice

Please note that for the sake of your health, we do not use the controversial amalgam. Among other things, we use biologically compatible cement fillings or all-ceramic inlays, so no metal.

Should you ever have pain or problems outside of your appointment, we offer special times for this. In this case we kindly ask you to make an appointment by phone in advance.

If you are unable to keep the appointment, please cancel by phone or in writing at least 24 hours before the agreed appointment (exception: sudden illness), otherwise the reserved time will have to be charged. We kindly ask for your understanding in this regard, as otherwise we cannot give important treatment time to other patients who may urgently need an appointment.

Please keep in mind that medication and anesthetic injections can impair your ability to react in traffic.

Please notify us immediately of any changes in your medical condition.

We hope you feel comfortable in our office and are happy to answer any questions you may have.


6. Declaration of consent for invoicing

I agree to dental fees - also for future treatments - being collected if the amount has not been paid within the agreed payment period despite several requests.

For this purpose, the dentist may pass on the data required in each case (in particular names, date of birth, address, date of treatment, service items, amounts, findings) to the debt collection agency and, if necessary, also to lawyers and courts for further processing.

This declaration is valid until I revoke it in writing.

You can find our privacy policy under this link.

Thank you for your cooperation. We look forward to welcoming you to our practice soon!