Becoming a Patient


Patient Registration Form

We would love to welcome you to the Alpstein Clinic. The first step in becoming a patient is to fill out the form below. Once received, one of our Patient Coordinators will be in touch with you to answer questions and provide detailed information about scheduling and the preparation of your personalized treatment plan and program.

Patient Form

    Contact Details

    Further Information

    Have you ever had surgery?

    Do you suffer from gum bleeding?

    Do you suffer from bad breath?

    Do you sometimes have a metallic taste?

    Have you undergone orthodontic treatment?

    Have you observed tooth migration?

    Do you have complaints while chewing?

    Do you have complaints in the jaw joint/ear area?

    Do you have head or neck pain?

    Do you take Marcumar/ Aspirin / ASS / blood thinners?

    Is there an increased tendency to bleed?

    Do you suffer from blood clotting disorders?

    Do you have an artificial hip joint or similar?

    Do you suffer from heart diseases?

    Do you have a heart stent?

    Do you have a pacemaker?

    Have you had a heart attack?

    Do you suffer from circulatory disorders?

    Do you have high blood pressure?

    Have you had liver disease, jaundice or hepatitis?

    Have you had a kidney disease?

    Have you had a lung disease?

    Do you suffer from tuberculosis/AIDS?

    Do you have an eye disease?

    Do you suffer from diabetes?

    Do you suffer from rheumatism?

    Do you suffer from osteoporosis, osteopenia, bone metabolic disorder?

    Do you suffer from epilepsy / seizure disorders?

    Do you have an allergy passport?

    Do you suffer from asthma, shortness of breath?

    Do you have allergies?

    Do you take medication regularly?

    Do you take antiresorptives/Medis which block bone metabolism? (Bisphosphonates)

    Have you undergone radiation treatments?

    May we use medical alcohol for disinfection?

    I am interested in holistic medical care

    Are you pregnant?

    Appointments that I cannot keep will be cancelled 24 hours in advance, otherwise, I will be charged for the costs incurred by the practice for the missed appointment. By signing, I confirm the accuracy of my information. Should there be any changes in my health status or insurance status during the treatment, I will inform the practice.

    Do you have intolerances (e.g. lactose, fructose, none, etc.)?

    Dental Information (Multiple answers possible)
    I have gum problemsI have teeth with amalgam fillingI have titanium implantsI have complaints of the masticatory muscles / temporomandibular jointI have teeth with root canal treatmentI have teeth with plastic fillingI have zirconium dioxide implantsI have a panoramic dental X-rayI have no dental complaints

    Type of Insurance*

    Basic Insurance

    Supplementary Insurance