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Register with our practice!

If you would like to register as a new patient at Tandartspraktijk Bouwman, you can use the form below.
It is important that all mandatory fields *) are filled in correctly and truthfully.

If you have any questions, don't hesitate to contact us.

First name *

Surname *

Address *

Postal code *

Residence *

Telephone number: *

E-mail address: *

Date of birth *

BSN number: *

Health insurance *

Policy number *

Last dentist visite *

Do you wish to make an appointment with the dentist and/or dental hygienist? If yes, with whom? *

Dentist

Dental Hygienist

None of the above

What day of the week do you prefer? Date:

Do you have a preference for a time? Time:

MEDICAL HISTORY

Has anything changed in your health in the past month? *

Yes

If so, please inform us

Are you allergic to anything particularly *

Yes

If so, for what substance

Did you had a heart attack? *

Yes

If so, when did this happen?

Do you surfer from palpitations? *

Yes

Are you following treatment for high bloodpressure? *

Yes

If so, what is your average bloodpressure?

Do you experience chest pain with exertion? *

Yes

Do you experience shortness of breath in bed? *

Yes

Do you have a heart valve deficiency or an artificial heart valve? *

Yes

Do you have a congenital heart defect? *

Yes

Have you ever experienced endocarditis? *

Yes

Do you have a pacemaker (or ICD) or neurostimulator? *

Yes

Have you ever passed out during a dental or medical procedure? *

Yes

Do you have epilepsy, falling sickness? *

Yes

Have you ever had a brain hemorrhage or stroke (or TIA)? *

Yes

Do you suffer from lung problems such as asthma, bronchitis or chronic cough? *

Yes

Are you suffering from diabetes? *

Yes

If so, do you use insulin?

Yes

Do you have anemia? *

Yes

Have you ever experience prolonged bleeding after tooth extractions? *

Yes

Do you have (or have had) hepatitis, jaundice or other liver disease? *

Yes

Do you suffer from kidney disease? *

Yes

Do you have rheumatism and/or chronic joint complaints? *

Yes

Have you been irradiated for a tumor in your head or neck? *

Yes

Do you smoke? *

Yes

If so, how many on a daily basis

Women: are you pregnant? *

Yes

Women: are you breastfeeding? *

Yes

Do you have a disease or condition which we did not mentioned in the above questions? *

Yes

If so, what kind of disease?

Did you used a medical prescription against osteoporosis (a bisphosphonate or denosumab) in the past? *

Yes

If so, which medicine?

Do you use any kind of medicines? *

Yes

If so, which medicine?

Can you provide us a medication history overview? *

Yes

Please bring this overview with you during your first appointment.

How did you hear about us? *

Through our flyer

Directed by a friend, family or relative

Search by Google

Anders:

Signature *

I hereby declare that I have filled in the information truthfully.

E-mailadres *

* Deze velden zijn verplicht.

Register with our practice!

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