{"id":1469,"date":"2022-03-21T14:26:09","date_gmt":"2022-03-21T13:26:09","guid":{"rendered":"http:\/\/ident-offenbach.de.w01c7b4e.kasserver.com\/?page_id=1469"},"modified":"2023-03-13T15:41:22","modified_gmt":"2023-03-13T14:41:22","slug":"online-anamnese","status":"publish","type":"page","link":"https:\/\/ident-offenbach.de\/en\/online-anamnese\/","title":{"rendered":"Online anamnesis"},"content":{"rendered":"<section class=\"l-section wpb_row us_custom_fbc88c1d header-section-w-img-portfolio height_auto width_full\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_grid cols_1 laptops-cols_inherit tablets-cols_inherit mobiles-cols_1 valign_middle type_default stacking_default\"><div class=\"wpb_column vc_column_container us_custom_f70d789f us_animate_this\"><div class=\"vc_column-inner\"><div class=\"ult-animation  ult-no-mobile\" data-animate=\"bounce\" data-animation-delay=\"0\" data-animation-duration=\"2\" data-animation-iteration=\"1\" style=\"\" ><div class=\"w-vwrapper us_custom_3d203104 align_center valign_middle\" style=\"--vwrapper-gap:0rem\"><div class=\"wpb_text_column us_custom_458bf724 has_text_color\"><div class=\"wpb_wrapper\"><p style=\"text-align: center;\">Online anamnesis<br \/>\nContact form<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_medium\" id=\"start\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_grid cols_1 laptops-cols_inherit tablets-cols_inherit mobiles-cols_1 valign_top type_default stacking_default\"><div class=\"wpb_column vc_column_container\"><div class=\"vc_column-inner\"><h5 style=\"text-align: left\" class=\"vc_custom_heading online-amnese-headline\" >Dear patients,<\/h5><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><p>Welcome to the iDent dental practice in Offenbach.<\/p>\n<p>We are pleased that you are putting your smile and your dental health in our hands!<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>You can complete the questionnaire on your state of health using the following PDF download or use our digital anamnesis form for direct contact.<\/p>\n<\/div><\/div><div class=\"w-separator size_small\"><\/div><div class=\"w-btn-wrapper align_none\"><a class=\"w-btn us-btn-style_1 icon_atleft\" title=\"Online Anamnesebogen\" target=\"_blank\" href=\"\/wp-content\/uploads\/2023\/03\/Anamnese-iDent.pdf\" rel=\"noopener\"><i class=\"fas fa-download\"><\/i><span class=\"w-btn-label\">PDF Download<\/span><\/a><\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1468-o1\" lang=\"de-DE\" dir=\"ltr\" data-wpcf7-id=\"1468\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/1469#wpcf7-f1468-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/1469#wpcf7-f1468-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1468\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"de_DE\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1468-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">1<\/span> Personal information\n<\/h5>\n<h5 class=\"online-amnese-subheadline\">Contact details of the patient\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column three_fourth\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Surname, first name *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_fourth last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>You are *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-gender\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"your-gender\"><option value=\"weiblich\">female<\/option><option value=\"m\u00e4nnlich\">male<\/option><option value=\"divers\">divers<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Date of birth *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-birthday\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-birthday\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Place of birth *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"place-of-birth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"place-of-birth\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"label-online-amnese\">\n\t\t<p>Street and house number *\n\t\t<\/p>\n\t<\/div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_fifth\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>ZIP *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-plz\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-plz\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column two_fifth\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Place of living\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-living-area\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-living-area\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column two_fifth last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>E-Mail *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Private phone\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone-no\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Cell *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-mobile-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-mobile-no\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"label-online-amnese\">\n\t\t<p>Occupation\n\t\t<\/p>\n\t<\/div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"job-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job-title\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Employer\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-employer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-employer\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Business phone\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-business-phone-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-business-phone-no\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>General practitioner\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-doctor\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-doctor\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Phone No.\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"doctors-phone-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"doctors-phone-no\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<h5 class=\"online-amnese-subheadline\">I am *\n\t<\/h5>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-ensurance\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-ensurance[]\" value=\"Gesetzlich versichert\" \/><span class=\"wpcf7-list-item-label\">Legally insured<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-ensurance[]\" value=\"Privat versichert\" \/><span class=\"wpcf7-list-item-label\">Privately insured<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-ensurance[]\" value=\"Zusatzversichert\" \/><span class=\"wpcf7-list-item-label\">Supplementary insured<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-ensurance[]\" value=\"Behilfeberechtigt\" \/><span class=\"wpcf7-list-item-label\">eligable to \"Beihilfe\"<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-ensurance[]\" value=\"Basistarif\" \/><span class=\"wpcf7-list-item-label\">Basistarif<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p>Please complete the following information, if you are not the main member of the medical insurance:\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-subheadline\">Contact details of the main insured person\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Surname, first name\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ensurance-contact-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ensurance-contact-name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Date of birth\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ensurance-contact-birthday\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ensurance-contact-birthday\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"label-online-amnese\">\n\t\t<p>Street and house number\n\t\t<\/p>\n\t<\/div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ensurance-contact-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ensurance-contact-address\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_third\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>ZIP\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ensurance-contact-plz\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ensurance-contact-plz\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column two_third last_column\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Place of living\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ensurance-contact-living-place\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ensurance-contact-living-place\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">2<\/span> Your concern\n<\/h5>\n<div class=\"cf7-row\">\n\t<h5 class=\"online-amnese-subheadline\">What is the reason for your visit? *\n\t<\/h5>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"reason-for-visit\"><span class=\"wpcf7-form-control wpcf7-checkbox check-aligned-underneath-each-other\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Routinekontrolle\" \/><span class=\"wpcf7-list-item-label\">Routine check<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Neuer Zahnersatz\" \/><span class=\"wpcf7-list-item-label\">New dentures<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Knirschen\" \/><span class=\"wpcf7-list-item-label\">Bruxism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Beratung\" \/><span class=\"wpcf7-list-item-label\">Consultation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Zweitmeinung\" \/><span class=\"wpcf7-list-item-label\">Second opinion<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"\u00c4sthetische W\u00fcnsche\" \/><span class=\"wpcf7-list-item-label\">Aesthetic desires<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Schmerzbehandlung\" \/><span class=\"wpcf7-list-item-label\">Pain therapy<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"reason-for-visit[]\" value=\"Zahnfleischbluten\" \/><span class=\"wpcf7-list-item-label\">Bleeding gums<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reason-for-visit-sonstiges\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other:\" value=\"\" type=\"text\" name=\"reason-for-visit-sonstiges\" \/><\/span>\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">3<\/span> General health issues\n<\/h5>\n<h5 class=\"online-amnese-subheadline\">Medical treatment *\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Are you currently undergoing medical treatment? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"arztliche-behandlung\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"arztliche-behandlung\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"arztliche-behandlung\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<p>Wenn ja, <b>If yes, which of the following medical conditions apply?<\/b>\n<\/p>\n<h5 class=\"online-amnese-subheadline-2\">Cardiac diseases\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Cardiac insufficiency<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-herzschwaeche\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"herzerkrankungen-herzschwaeche\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"herzerkrankungen-herzschwaeche\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Pacemaker \/ artificial heart valve? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-herzschrittmacher\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"herzerkrankungen-herzschrittmacher\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"herzerkrankungen-herzschrittmacher\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Angina Pectoris? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-angina-pectoris\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"herzerkrankungen-angina-pectoris\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"herzerkrankungen-angina-pectoris\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Condition after myocardial infarction? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-nach-herzinfarkt\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"herzerkrankungen-nach-herzinfarkt\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"herzerkrankungen-nach-herzinfarkt\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Congenital heart defect? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-geb-herzfehler\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"herzerkrankungen-geb-herzfehler\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"herzerkrankungen-geb-herzfehler\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"herzerkrankungen-sonstiges\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other?\" value=\"\" type=\"text\" name=\"herzerkrankungen-sonstiges\" \/><\/span>\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Cardiovascular diseases\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>High blood pressure? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kreislauf-high-blutdruck\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"kreislauf-high-blutdruck\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"kreislauf-high-blutdruck\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Low blood pressure? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kreislauf-low-blutdruck\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"kreislauf-low-blutdruck\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"kreislauf-low-blutdruck\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"welche-sonstigen-kreislauferkrankungen\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other?\" value=\"\" type=\"text\" name=\"welche-sonstigen-kreislauferkrankungen\" \/><\/span>\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Infectious diseases\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Tuberculosis? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-hepatitis\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"infektion-hepatitis\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"infektion-hepatitis\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Tuberkulose? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-tuberkulose\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"infektion-tuberkulose\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"infektion-tuberkulose\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>HIV? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-hiv\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"infektion-hiv\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"infektion-hiv\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Covid-19? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-covid\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"infektion-covid\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"infektion-covid\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Have you had any endoprostheses or implants fitted? *<br \/>\n(e.g. hip, knee, heart valve, pacemaker, stents.)<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-endoprothesen\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"infektion-endoprothesen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"infektion-endoprothesen\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<p><label>If yes, which ones?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"infektion-endoprothesen-welche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"infektion-endoprothesen-welche\" \/><\/span>\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Metabolic diseases\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Diabetes? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-diabetes\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-diabetes\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-diabetes\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you need insulin? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-insulinpflicht\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-insulinpflicht\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-insulinpflicht\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row-hba1c\">\n\t<div class=\"label-online-amnese-hba1c\">\n\t\t<p>HbA1c value?\n\t\t<\/p>\n\t<\/div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-hba1c\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stoffwechsel-hba1c\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Thyroid diseases? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-schilddruesen\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-schilddruesen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-schilddruesen\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Kidney disease? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-nieren\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-nieren\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-nieren\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Gastrointestinal diseases?* <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-magen-darm\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-magen-darm\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-magen-darm\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Crohn's disease? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-morbus-crohn\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-morbus-crohn\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-morbus-crohn\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Ulcerative colitis? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-colitis\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-colitis\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-colitis\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Liver diseases? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stoffwechsel-leber\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stoffwechsel-leber\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stoffwechsel-leber\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Diseases of the nervous system\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Epileptic seizures? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nervensystem-epilepsie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"nervensystem-epilepsie\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"nervensystem-epilepsie\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Depression? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nervensystem-depressionen\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"nervensystem-depressionen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"nervensystem-depressionen\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Other diseases and information\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Rheumatism? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-erkrankung-rheuma\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sonstige-erkrankung-rheuma\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sonstige-erkrankung-rheuma\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Multiple sclerosis? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-erkrankung-sklerose\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sonstige-erkrankung-sklerose\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sonstige-erkrankung-sklerose\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Lung diseases? (asthma, embolism) *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-erkrankung-lunge\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sonstige-erkrankung-lunge\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sonstige-erkrankung-lunge\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Nasal\/sinus diseases?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-erkrankung-nase\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sonstige-erkrankung-nase\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sonstige-erkrankung-nase\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Other medical conditions? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-erkrankung-sonstiges\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sonstige-erkrankung-sonstiges\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sonstige-erkrankung-sonstiges\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>If yes, which ones?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"welche-sonstige-erkrankungen\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"welche-sonstige-erkrankungen\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">4<\/span> Special health issues\n<\/h5>\n<h5 class=\"online-amnese-subheadline-2\">Medication\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you take any medication regularly? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-nehmen\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-nehmen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-nehmen\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>If yes, which ones?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-welche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"meds-welche\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Are you taking blood thinners? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-blutverduenner\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-blutverduenner\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-blutverduenner\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>If yes, which ones?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-blutverduenner-welche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"meds-blutverduenner-welche\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Are you taking medication<br \/>\nfor osteoporosis or tumour diseases? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-tumore\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-tumore\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-tumore\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Are you taking or have you taken bisphosphonates? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-bisphosphonate\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-bisphosphonate\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-bisphosphonate\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Have you undergone chemotherapy\/radiotherapy? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"meds-chemo\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"meds-chemo\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"meds-chemo\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<h5 class=\"online-amnese-subheadline-2\">Allergies\n<\/h5>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you have any suspected hypersensitivity or allergies to certain materials or medications? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-verdacht\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergien-verdacht\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergien-verdacht\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>If yes, which ones?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-welche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergien-welche\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you have an allergy pass card? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-pass\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergien-pass\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergien-pass\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you smoke? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-rauchen\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergien-rauchen\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergien-rauchen\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you regularly consume alcohol or other intoxicants? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-rauschmittel\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergien-rauschmittel\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergien-rauschmittel\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>Do you take stimulants or tranquillisers? *<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-beruhigungsmittel\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergien-beruhigungsmittel\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergien-beruhigungsmittel\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<div class=\"content-column one_half\">\n\t\t<p><label>If yes, which ones?<\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"content-column one_half last_column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-beruhigungsmittel-weche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergien-beruhigungsmittel-weche\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"clear_column\">\n<\/div>\n<div class=\"cf7-row\">\n\t<h5 class=\"online-amnese-subheadline-2\">For female patients\n\t<\/h5>\n\t<p><label>Are you pregnant?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"are-you-pregnant\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"are-you-pregnant\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"are-you-pregnant\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<h5 class=\"online-amnese-subheadline-2\">COVID-19 vaccination\n\t<\/h5>\n\t<p><label>Have you been vaccinated against Covid-19? *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"covid-impfung\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"covid-impfung\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"covid-impfung\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row\">\n\t<h5 class=\"online-amnese-subheadline-2\">Prophylaxis (PTC) flat rate\n\t<\/h5>\n\t<p><label>Do you have a prophylaxis (PTC) flat rate?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pzr-flatrate\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pzr-flatrate\" value=\"Ja\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pzr-flatrate\" value=\"Nein\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nPlease get in touch if you are interested.\n\t<\/p>\n<\/div>\n<h5 class=\"online-amnese-subheadline\">How did you hear about us?\n<\/h5>\n<div class=\"cf7-row\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"empfehlung-from-where\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"empfehlung-from-where\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"cf7-row-unterschrift\">\n\t<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">5<\/span> Declaration and data privacy\n\t<\/h5>\n\t<div class=\"datenschutz-subheadlines-online-amnese\">\n\t\t<p>Information on the ability to drive after dental treatment\n\t\t<\/p>\n\t<\/div>\n\t<p>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.\n\t<\/p>\n\t<div class=\"datenschutz-subheadlines-online-amnese\">\n\t\t<p>Declaration of consent for X-ray\n\t\t<\/p>\n\t<\/div>\n\t<p>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.\n\t<\/p>\n\t<div class=\"datenschutz-subheadlines-online-amnese\">\n\t\t<p>Data protection information and declaration of consent to data processing in accordance with the EU GDPR\n\t\t<\/p>\n\t<\/div>\n\t<p>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.\n\t<\/p>\n\t<div class=\"datenschutz-subheadlines-online-amnese\">\n\t\t<p>Conduction anaesthesia\n\t\t<\/p>\n\t<\/div>\n\t<p>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<br \/>\n(sensory disturbances, pain and discomfort, numbness, loss of taste, etc.).\n\t<\/p>\n\t<p>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.\n\t<\/p>\n\t<p>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.\n\t<\/p>\n\t<div class=\"datenschutz-subheadlines-online-amnese\">\n\t\t<p>Appointments &amp; health insurance card\n\t\t<\/p>\n\t<\/div>\n\t<p>We are an appointment practice and ask you to cancel appointments that you cannot keep <strong>at least 24 hours in advance<\/strong> . Otherwise we will have to charge you a cancellation fee (\u20ac100\/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.\n\t<\/p>\n\t<h5 class=\"online-amnese-subheadline\">Confirmation &amp; currency of your information\n\t<\/h5>\n\t<div class=\"cf7-row-einwilligung\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"datenschutz-unterschrift\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"datenschutz-unterschrift\" value=\"1\" class=\"unterschrift-online-amnese\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><strong>I have completed this questionnaire to the best of my knowledge and confirm with my signature that the information provided is complete and correct. I will inform you of any changes accordingly. *<\/strong><\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row-datenschutz\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"datenschutz\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"datenschutz\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><strong>I have read the <a href=\"\/en\/datenschutz\/\">Data privacy statement<\/a> gelesen und akzeptiere diese. *<\/strong><\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\" style=\"padding-bottom: 1rem;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"einwilligung-ort-datum\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Place, date *\" value=\"\" type=\"text\" name=\"einwilligung-ort-datum\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h5 class=\"online-amnese-headline\"><span class=\"online-amnese-no\">6<\/span> Invoice and reimbursement\n\t<\/h5>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Surname \/ first Name *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rechnung-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rechnung-name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Date of birth *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rechnung-birthday\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rechnung-birthday\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>Street \/ No. *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rechnung-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rechnung-address\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"label-online-amnese\">\n\t\t\t<p>ZIP \/ Place of living *\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rechnung-plz-residence\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rechnung-plz-residence\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row-unterschrift\" style=\"margin-top:1.5rem;\">\n\t\t<div class=\"datenschutz-subheadlines-online-amnese\" style=\"margin-bottom: 1.5rem;\">\n\t\t\t<p>Dear patient,\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p>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.\n\t\t<\/p>\n\t\t<p>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.\n\t\t<\/p>\n\t\t<ul>\n\t\t\t<li>\n\t\t\t\t<p>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).\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p>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.\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p>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\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t<\/ul>\n\t\t<p>Invoicing <strong>(\"billability\")<\/strong> and reimbursement <strong>(\"reimbursability\")<\/strong> 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\").\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row-einwilligung\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rechnung-unterschrift\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"rechnung-unterschrift\" value=\"1\" class=\"unterschrift-online-amnese\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><strong>I have been sufficiently informed about the reimbursement issue. I have understood the issues raised. Even if the reimbursement centre does not reimburse the invoice amount shown on the invoice or does not reimburse it in full, I am aware that I will be liable to pay the dentist the total amount. *<\/strong><\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\" style=\"padding-bottom: 1rem;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"einwilligungrechnung-ort-datum\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Place, date *\" value=\"\" type=\"text\" name=\"einwilligungrechnung-ort-datum\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cf7-row\" style=\"margin-top: 40px;\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n\t\t<\/p>\n\t<\/div>\n\t<p>* mandatory\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><\/section>","protected":false},"excerpt":{"rendered":"Online Anamnese Kontaktformular Liebe Patienten,willkommen in der Zahnarztpraxis iDent in Offenbach. Wir freuen uns, dass Sie uns Ihr L\u00e4cheln und Ihre Zahngesundheit anvertrauen! Unser Ziel ist es, Ihnen eine bestm\u00f6gliche und individuelle Behandlung anzubieten. Bevor wir uns aber mit Ihnen \u00fcber Ihre zahnmedizinischen W\u00fcnsche unterhalten, ben\u00f6tigen wir neben Ihren Personalien auch Angaben \u00fcber Ihren allgemeinen...","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1469","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Online Anamnese - Zahnarzt Offenbach Bieber | Zahnarztpraxis iDent<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/ident-offenbach.de\/en\/online-anamnese\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Online Anamnese - Zahnarzt Offenbach Bieber | Zahnarztpraxis iDent\" \/>\n<meta property=\"og:url\" content=\"https:\/\/ident-offenbach.de\/en\/online-anamnese\/\" \/>\n<meta property=\"og:site_name\" content=\"Zahnarzt Offenbach Bieber | Zahnarztpraxis iDent\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/ZahnarztpraxisiDent\/\" \/>\n<meta property=\"article:modified_time\" content=\"2023-03-13T14:41:22+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Estimated reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/ident-offenbach.de\\\/online-anamnese\\\/\",\"url\":\"https:\\\/\\\/ident-offenbach.de\\\/online-anamnese\\\/\",\"name\":\"Online Anamnese - Zahnarzt Offenbach Bieber | Zahnarztpraxis iDent\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/ident-offenbach.de\\\/#website\"},\"datePublished\":\"2022-03-21T13:26:09+00:00\",\"dateModified\":\"2023-03-13T14:41:22+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/ident-offenbach.de\\\/online-anamnese\\\/#breadcrumb\"},\"inLanguage\":\"en-GB\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/ident-offenbach.de\\\/online-anamnese\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/ident-offenbach.de\\\/online-anamnese\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Startseite\",\"item\":\"https:\\\/\\\/ident-offenbach.de\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Online Anamnese\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/ident-offenbach.de\\\/#website\",\"url\":\"https:\\\/\\\/ident-offenbach.de\\\/\",\"name\":\"Zahnarzt Offenbach Bieber | Zahnarztpraxis iDent\",\"description\":\"Thomas Balogh &amp; 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