Health form

Læs mere om hvordan Specialtandlæger i Bredgade håndterer, bruger og beskytter dine personoplysninger for at tilpasse og forbedre din brugeroplevelse.

Name of patient *

Social security number *

Address

Street

Postal code *

City *

Contact information

Telephone number *

Email address *

Hvis du valgte ‘Andet’, bedes du specificere her:

Questions

To ensure we give you the best possible treatment, we kindly ask you to answer the following questions

Are you currently undergoing treatment at a hospital? *

Have you previously experienced any problems with local anasthesia? *

Have you previously experienced prolonged bleeding after tooth extractions or other surgeries? *

Do you smoke? *

Are you a member of sygesikring Danmark? *

Sygesikring Danmark group

Diseases

Do you suffer from any of the following diseases:

Asthma? *

Diabetes? *

Cardiovascular diseases? *

Hypertension (high blood pressure)? *

Osteoporosis? *

Epilepsy *

Cancer *

HIV/AIDS *

MRSA? (methicillin resistant staphyloccoci) *

Hepatitis *

Immunodeficiency disorders *

Other severe diseases? *

May we request a copy of your dental and medical records as well as x-ray from your dentist or medical doctor/physician? *

May we use your data for teaching and research in anonymized form? *

Are you pregnant or breastfeeding? *

Have you ever recieved radiotherapy in the head/neck area? *

Do you tolerate penicillin? *

Do you tolerate NSAID (ibuprofen)? *

Are you allergic to any other types of medication? *

Have you previously undergone surgery in jaws or sinuses of the head? *

Do you take any medication (prescription or other)? *

Medical doctor/physician

Would you like to give us contact information for a doctor who has treated you?

Name of the doctor

Street

Postal code

City

Telephone number

Own dentist

Would you like to give us contact information for a dentist who has treated you?

Name of dentist

Street

Postal code

City

Telephone number

Signature *

I consent to the use of clinical photographs, X-rays and medical records for quality assurance purposes. I understand that consent is voluntary and that I can withdraw my consent at any time without losing my current or future rights to treatment.