Admission document orthodontics adults | Dental Practice Zürichsee Pfäffikon SZ

Health Questionnaire

In order to advise you personally and to apply any possible medication for your protection correctly, we need certain specifications regarding your health. All your information is subject to our doctor's duty of confidentiality.

Please check where applicable::

1. Did you ever have::

   Problems with bleeding over a long period of time?

   YES NO

   Cardiac or circulatory troubles?

   YES NO

   Diabetes and/or other metabolic disorders?

   YES NO

   Asthma or other allergies of any sort?

   YES NO

   Another serious illness?

   YES NO If yes, which?

2. Do you have to take medication on a regular basis?

   YES NO

3. Did you have your pharyngeal or palatine tonsils removed?

   YES NO

4. Did you ever have a tooth accident?

   YES NO

5. Did you ever have speech therapy?

   YES NO

6. Did you ever have your teeth corrected?

   YES NO

7. Do you play a wind instrument?

   YES NO

administrative matters

8. Do you receive social welfare or supplementary benefits?

   YES NO If yes, which social welfare office?

9. Would you like a reminder SMS for your appointments?

   YES NO

Referral/Recommendation

10. Referring dentist or by whom we were recommended:

Privacy policy

11. I confirm with my signature that I agree to the processing of my data, the access to the data by the doctor and the disclosure of the data to third parties in accordance with the Patient Information/Data Protection Act until further notice.

    YES NO

12. I confirm that my data may be passed on to external service providers (laboratories etc.) via a secure data connection within the scope of orders.

    YES NO

13. I agree that the collection procedure of dental fees (including future treatments) may be carried out by a collection agency. The necessary data for this purpose may be passed on to the relevant collection agency by the dentist.

    YES NO