DENTAL PRACTICE
RENÉ
Practice for Biological & General Dentistry - Amsterdam/Osdorp since 1983
020 610 2883
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Registration form
Registration form
Step 1 of 5
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Personal Information:
First name:
*
Family name:
*
Maiden name:
Initials:
*
Date of birth:
*
Sex:
*
Male
Female
Address:
Address:
*
Street Address
City
ZIP / Postal Code
Telephone Home
*
Telephone Work
Telephone Mobile
*
E-mail address
*
BSN
*
Dutch social security number.
Occupation
Insurance
Basic Health Insurer
*
Policy Number
*
Your number at your insurer
Are you insured for dental costs?
*
Yes
No
With the same insurer as above?
*
Yes
No
If no, what is the name and policy number of your dental insurer?
What is your maximum coverage for dental per year?
*
Questions about your dental history:
When was your last visit to the dentist?
*
First visit to the dentist
Less than 6 months ago
Less than a year ago
Less than 2 years ago
More than 2 years ago
More than 5 years ago
What treatment was done?
Check-up
Emergency treatment
Other treatment
Why did you leave your last dentist?
Have you ever been to dental hygienist for treatment?
Yes
No
Why did you choose to come to Tandarts Praktijk René (You can check more than one answer)*
*
Moved
Haven't been to dentist for a long time
I have pain
I would like a biological dentist
Fear
Problems with dentures
Unhappy with teeth
Amalgam removal
Other: (fill in below)
Other:
How did you find out about our practice?
*
Tandarts.nl or another on-line dentist search engine
Newspaper Ad
Amalgaam Vrij Nederland website
Waled past the practice
Sent by a Dr. of therapist
Recommendation by a friend or family member
Website/Google
Facebook
Other
Dental Questionnaire
Are you happy with the current condition of your teeth?
*
Yes
No
Do you have problems with your teeth or gums?
*
Yes
No
If yes can you briefly state the problem/s?
Are your teeth sensistive to:
Temperature changes?
No
Yes
Sugar?
No
Yes
Chewing or biting?
No
Yes
Do you have bleeding gums?
No
Yes
Do you have loose teeth?
No
Yes
How often do you brush your teeth per day?
0x
1x
2x
3x or more
Do you smoke?
No
Yes
Are there things we should be aware of?
What do you find important in your relationship with your dentist?
Do you have any other requests or questions?
Do you have a preference for a dentist in our practice? If so, which one?
René van der Bijl
Inna Popova
Gina Aizic
Alja de Graaff
Diana Cajamarca
Athina Georgiou
Elvira Gligor
no preference
Do you want to register other family members? If so, could you write their names, dates of birth, and social security number here?