Registration form

Please note that all of your answers fall under our dentist-patience privilege and are therefore related to medical confidentiality.

During your ‘First Visit’ appointment, please remember to bring a valid identification document along with your insurance card and an up-to-date medication/health overview if you have one.

When registering as a patient at Qyom Tandartsen we kindly ask you to obtain your dental records from your previous dentist.

Your details (or the details of your child)

MaleFemale

 

 

 

During your ‘First Visit’ appointment, you and your dentist shall discuss a comprehensive health certificate about the relevant condition of your teeth. To this end, we shall ask you to fill out a questionnaire about your health.