Formulario de inscripción Patient information Anmeldeformular Apellidos Surname Nachname Nombres Name Vorname Fecha de nacimiento Date of birth Geburtsdatum Nacionalidad Nationality Nationalität
Dirección Address Anschrift
Teléfono Phone number Telefon Correo electrónico Email E-Mail ¿Toma Ud. alguna medicina? ¿Cuál? Are you taking any current medication? Welche Medikamente nehmen Sie?
¿Tiene Ud. alguna enfermedad del corazón o de la circulación? Do you have heart or circulation condition? Haben Sie HerzKreislaufbeschwerden?
¿Tiene Ud. alguna alergia a medicamentos? Do you have any allergies to medication? Haben Sie Allergien gegen Medikamenten?
¿Sangran mucho sus heridas? ¿Toma Ud. anticoagulantes? Do you suffer bleeding problems? Are you taking anticoagulants?
Bluten Ihre Verletzungen lange? Nehmen Sie Blutverdünner?
¿Tiene Ud. alguna otra enfermedad (diabetes, asma, etc.)? Do you have any other diseases (diabetes, asthma, etc)? Haben Sie sonstige Krankheiten (Diabetes, Asthma)?
¿Está Ud. embarazada? Are you pregnant? Sind Sie schwanger? Yes No Firma Signature Unterschrift
Fecha Date Datum
/
/ 2017
Missed appointments may result in a 20 euro penalty.
¿Como ha encontrado la clinica? How did you hear about us? Wie haben Sie uns gefunden?
Radio
Gazette
Google
Recommendation
Date:
Recall 3 / 6 / 9 / 12
Visual examination
Filling #_________________
Bridge recement #_________
Consultation
Full Check up 2 bite wings
Medicated filling #________
RCT Extirpation #__________
Antibiotics Perscription
Scale and polish
Extraction #_____________
RCT core rebuild #_________
Emergency supplement
Scale and polish Crystal White Crown Preparation #______
Denture impressions
Dontisolon treatment
Periapical X-Ray ___________ Crown Recement
OPG X-Ray
See notes
Date:
Recall 3 / 6 / 9 / 12
Visual examination
Filling #_________________
Bridge recement #_________
Consultation
Full Check up 2 bite wings
Medicated filling #________
RCT Extirpation #__________
Antibiotics Perscription
Scale and polish
Extraction #_____________
RCT core rebuild #_________
Emergency supplement
Scale and polish Crystal White Crown Preparation #______
Denture impressions
Dontisolon treatment
Periapical X-Ray ___________ Crown Recement
OPG X-Ray
See notes
Date:
Recall 3 / 6 / 9 / 12
Visual examination
Filling #_________________
Bridge recement #_________
Consultation
Full Check up 2 bite wings
Medicated filling #________
RCT Extirpation #__________
Antibiotics Perscription
Scale and polish
Extraction #_____________
RCT core rebuild #_________
Emergency supplement
Scale and polish Crystal White Crown Preparation #______
Denture impressions
Dontisolon treatment
Periapical X-Ray ___________ Crown Recement
OPG X-Ray
See notes
Date:
Recall 3 / 6 / 9 / 12
Visual examination
Filling #_________________
Bridge recement #_________
Consultation
Full Check up 2 bite wings
Medicated filling #________
RCT Extirpation #__________
Antibiotics Perscription
Scale and polish
Extraction #_____________
RCT core rebuild #_________
Emergency supplement
Scale and polish Crystal White Crown Preparation #______
Denture impressions
Dontisolon treatment
Periapical X-Ray ___________ Crown Recement
OPG X-Ray
See notes
