Online anamnesis
Contact form

Dear patients,

Welcome to the iDent dental practice in Offenbach.

We are pleased that you are putting your smile and your dental health in our hands!

Our aim is to offer you the best treatment possible, personalised to your needs. However, before we talk to you about your dental wishes, we need your personal details as well as information about your general state of health. This is important for adequate and minimised risk treatment. We would therefore ask you to take a moment to read this questionnaire carefully and complete it as accurately as possible. We will gladly discuss the key questions and answers with you in detail.

We kindly ask you to inform us of any future changes of your state of health and your address. It goes without saying that all your details are subject to medical confidentiality.

You can complete the questionnaire on your state of health using the following PDF download or use our digital anamnesis form for direct contact.

    1 Personal information
    Contact details of the patient

    Surname, first name *

    You are *

    Date of birth *

    Place of birth *

    Street and house number *

    ZIP *

    Place of living

    E-Mail *

    Private phone

    Cell *

    Occupation

    Employer

    Business phone

    General practitioner

    Phone No.

    I am *

    Please complete the following information, if you are not the main member of the medical insurance:

    Contact details of the main insured person

    Surname, first name

    Date of birth

    Street and house number

    ZIP

    Place of living

    2 Your concern
    What is the reason for your visit? *


    3 General health issues
    Medical treatment *

    YesNo

    Wenn ja, If yes, which of the following medical conditions apply?

    Cardiac diseases

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Cardiovascular diseases

    YesNo

    YesNo

    Infectious diseases

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo


    Metabolic diseases

    YesNo

    YesNo

    HbA1c value?

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Diseases of the nervous system

    YesNo

    YesNo

    Other diseases and information

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    4 Special health issues
    Medication

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Allergies

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    For female patients


    YesNo

    COVID-19 vaccination


    YesNo

    Prophylaxis (PTC) flat rate


    YesNo
    Please get in touch if you are interested.

    How did you hear about us?

    5 Declaration and data privacy

    Information on the ability to drive after dental treatment

    Please note that your ability to drive may be impaired for up to 24 hours after dental treatment. This can be caused both by the treatment itself and by the influence of injections or other medication.

    Declaration of consent for X-ray

    I hereby give my consent for any necessary X-ray examinations to be carried out on me as part of the dental treatment. I hereby consent to the iDent dental practice obtaining findings and treatment data (e.g. existing x-rays) from other service providers (e.g. orthodontist / general practitioner) and transmitting findings obtained in the practice to co-treating doctors.

    Data protection information and declaration of consent to data processing in accordance with the EU GDPR

    We would like to take this opportunity to inform you that personal data is collected and stored in the course of dental treatment in our practice. The collection and storage of the data is necessary for the treatment in accordance with Art. 6 para. 1 b) EU GDPR. By signing this page, you expressly consent to the collection and storage of personal data necessary for your treatment. You have the right to revoke this consent at any time, but a revocation is only effective for the future, as documentation of your treatment data is mandatory according to legal regulations. However, once this declaration of consent has been revoked, further treatment is no longer possible. Further information on data protection, which rights you have with regard to data protection or information on the purpose for which our practice collects, stores or forwards data can be obtained from our front desk upon request at any time.

    Conduction anaesthesia

    I hereby confirm that I have been informed about the treatment risks of a conduction anaesthesia. It was explained to me in detail what is meant by "conduction anaesthesia" and what treatment risks may arise during surgical and/or conservative/prosthetic treatments if conduction anaesthesia is used in the lower jaw. It was explained to me, among other things, that possible damage to the lingual nerve and/or the mandibular nerve is a very rare risk, but one that cannot be ruled out, which may lead to permanent impairments
    (sensory disturbances, pain and discomfort, numbness, loss of taste, etc.).

    I am also aware that the anaesthetic can cause allergic reactions. Headaches and slight dizziness may occur. In addition, the ability to react and concentrate may be reduced, which is particularly important to bear in mind when actively participating in road traffic.

    I hereby give my explicit consent to the administration of a general anaesthetic in connection with the dental treatment I have requested. I wish to receive adequate pain relief during dental treatment.

    Appointments & health insurance card

    We are an appointment practice and ask you to cancel appointments that you cannot keep at least 24 hours in advance . Otherwise we will have to charge you a cancellation fee (€100/hour). We also require your health insurance card for every visit to the practice. If we do not receive it 14 days after the treatment, we will have to treat you as a private patient and you will receive an invoice.

    Confirmation & currency of your information

    6 Invoice and reimbursement

    Surname / first Name *

    Date of birth *

    Street / No. *

    ZIP / Place of living *

    Dear patient,

    Experience has shown that when it comes to reimbursement of costs by private health insurers, supplementary dental insurers and state aid organisations, discussions about reimbursement occur very frequently.

    The reasons for this lie in the difference between the two legal relationships to be taken into account in the context of private treatment, which must be kept strictly separate.

    • On the one hand, there is the legal relationship between the patient and the dentist. On the other hand, there is a second, independent legal relationship between the patient and the reimbursing organisation (private health insurance or subsidy office).

    • In the legal relationship between patient and dentist, the provisions of the scale of fees for dentists and doctors apply without exception to the fee structure. In case of doubt, the dentist shall be guided by the legal opinions of the Federal Chamber or the responsible Dental Association.

    • In the legal relationship between the patient and the cost-reimbursing organisation, however, in addition to the scale of fees for dentists, the provisions of the insurance contract, collective agreement regulations, aid guidelines and, last but not least, the opinion of the cost-reimbursing organisation on the regulatory provisions of the scale of fees also apply. As a result, the cost-reimbursement organisation sometimes makes differing interpretations, demands and sometimes subjective statements when processing invoices and treatment plans, which often contradict the dentists' views on the scale of fees

    Invoicing ("billability") and reimbursement ("reimbursability") are two separate legal processes. Therefore, the dentist may not invoice according to the ideas of the reimbursing organisation. The dentist has no influence on the reimbursement of the fees and fee items listed in the dental invoice by private health insurance companies or subsidy offices ("Beihilfestellen").

    * mandatory

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