Anmeldeformular | Health Point

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Patient Registration Form

Last Name

First Name

Address

Number

ZIP Code

Town

Country

Phone Number

Mobile Phone Number

Email Address

Gender

Marital Status

Date of Birth

Emergency Contact

Last Name

First Name

Address

Number

Zip Code

Town

Country

Phone Number

Mobile Phone Number

Health Insurance

Name of your basic health insurance

Name of your supplementary health insurance

Medical History

1. Main Medical Complaint

2. Other Diseases

3. Operations

4. Family Medical History

5. Additional Burdens (social environment, electromagnetism, mold pollution in the living area, etc.)

6. Medication

7. Dental Status

Gum Problems

Titanium Implants, Zirconium Dioxide Implants

Amalgam or other Fillings

Root Canal treated Teeth

8. Diet

9. Allergies

10. Do you consume...

alcohol

smoke

other drugs

11. Which doctors are you currently seeing?

Name

Address

How did you hear about us?

Notes

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Health Point Dr. Klein AG Rütihofstrasse 1 CH-9052 Niederteufen P +41 71 840 03 46 info@healthpointag.ch www.healthpointag.ch

[dr.klein@hin.ch for patient findings]

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