Registration

We are taking on new patients at Ivoren Toren Hilversum Dental Practice.

Would you be so kind to fill in the registration form below? We need a separate form for each family member and please include as much detail as possible. Your details will be kept confidential. Once we receive your form we will be in touch as soon as possible. All the questions below are mandatory. The security question regarding if you’re a human or not is to protect us against malicious cyber attacks. Please enter ‘ja‘ as you’re obviously human!

At the time of your first appointment with us your registration will become official.
Important: Please bring a valid ID with you on your first visit to the practice!

Ivoren Toren Dental Practice Registration Form

Please answer all sections indicated by a *

Patient information
Initials and Surname*
First name*
Date of Birth*
Sex*	Male Female
Street address and house number*
Postcode*
Town/City*
Telephone number*
Mobile Telephone number
E-mail*
Dutch registration number*

General practitioner
Who is your GP?*
Town/City*

Pharmacy
Who is your pharmacy?*
Town/City*

Insurance
Insurance Company name*
Insurance policy number*
Insurance start date*

When was the last time you visited the dentist?

Please have your current dentist forward your records to our healthcare email address: 500117116@lms.lifeline.nl

General health questionnaire

Using this questionnaire will inquire about your medical history and use of medication, which can influence your oral health . This can have limiting effect on the treatment or the precautions we may have to take. Thanks to this list, we can determine any possible risk that a treatment could have. These records will be treated with the up most care and confidentiality.

Click on Yes or No and complete if necessary.
Your answers will be treated with the up most care and confidentiality.

1.	Has anything changed to you health, in the last couple of months? If yes, what?	Yes / No
2.	Are you being treated by a medical specialist? If yes, what for?	Yes / No
3.	In the last couple of years, have you been admitted to a hospital? If yes, what for?	Yes / No
4.	Have you ever had a life threating disease? If yes, with disease?	Yes / No
5.	Are you allergic to anything? If yes, what for?	Yes / No
6.	Have you ever had a heart-attack? If yes, when?	Yes / No
7.	Have you ever had palpitations?	Yes / No
8.	Are you being treated for high blood pressure? If yes, what is your pressure usually? Non-Systolic pressure Systolic pressure	Yes / No
9.	Do you ever have pain to the chest when you’re emotional or exercising?	Yes / No
10.	Do you ever have swollen ankles or feet?	Yes / No
11.	Are you ever short of breath when you lie down?	Yes / No
12.	When exercising, do you ever get short of breath?	Yes / No
13.	Do you have a vulvar problem or an artificial heart?	Yes / No
13a.	Do you have an artificial knee or hip?	Yes / No
14.	Do you have a congenital heart defect?	Yes / No
15.	Do you have a pacemaker (or ICD)?	Yes / No
16.	Are you in the care of the thrombosis service?	Yes / No
17.	Have you ever fainted during a dental or medical treatment?	Yes / No
18.	Do you ever suffer from hyperventilation?	Yes / No
19.	Do you have epilepsy?	Yes / No
20.	Have you ever had a cerebral hemorrhage or stroke?	Yes / No
21.	Do you have respiratory problems like asthma, bronchitis or chronic cough? If yes, are you short of breath as well? Yes / No	Yes / No
22.	Are you diabetic? If yes, do you use insuline? Yes / No	Yes / No
23.	Are you anemic?	Yes / No
23a.	Do you have a blood disease/blood clogging disorder?	Yes / No
24.	Have you ever had long term bleeds, after pulling a tooth or after an operation?	Yes / No
25.	Do you have (or never had) hepatitis, jaundice or any other lever disease?	Yes / No
26.	Do you have kidney disease?	Yes / No
27.	Do you have chronic bowel problems?	Yes / No
28.	Do you have a condition of the thyroid?	Yes / No
29.	Are you rheumatic and/or do you have chronic joint problems?	Yes / No
30.	Do you have a contagious disease? If yes, with disease?	Yes / No
30a.	Do you suffer from depression?	Yes / No
30b.	Have you visited a psychologist or psychiatrist in recent years?	Yes / No
31.	Have you ever received radiation treatment for a tumor to your head or neck?	Yes / No
32.	Do you smoke? If yes, how many?	Yes / No
33.	Do you consume alcohol? If yes, how many?	Yes / No
34.	Do you, or did you ever use drugs? If yes, which?	Yes / No
35.	Are you pregnant? if yes, what is your due date?	Yes / No
36.	Do you have a disease or condition not listed above? If yes, which?	Yes / No
37.	Do you currently use medication? If yes, please write down what you use: (We would also like to receive a medicine list from your pharmacist)	Yes / No
38.	Leave your comments here

For security reasons we have to ask, are you human?*