New Patient Registration — Tandartsenpraktijk Coolhaven Rotterdam

Personal details

Enter your basic information. Fields marked with * are required.

Name & Date of Birth

First name(s) *

Last name(s) *

Date of birth *

Gender

Address

Street and house number *

Postal code *

City *

Contact details

Phone number *

Email address *

Preferred contact method

Preferred language

Insurance

Health insurer *

Policy number

General practitioner & Previous dentist

Name of GP

Phone number GP

Name of previous dentist

Phone number previous dentist

Financial management

Who manages your finances?

Reason for registration

Remarks

I would like a free introductory consultation and tour of the practice

I have dental anxiety — please give extra attention to this

I would like to receive appointment reminders by SMS

Step 1 of 3

Medical history

Answer the questions below as completely as possible. Click Yes or No for each question. This information is necessary for your safety during treatments.

Heart & Blood Vessels

1. Do you experience chest pain or tightness during physical exertion (angina pectoris)?
2. Have you had a heart attack?
3. Do you have a heart murmur or heart valve defect?
4. Do you have an artificial hip or an artificial heart valve?
5. Have you had vascular surgery less than 6 months ago?
→ Do you need antibiotics for dental treatment?
6. Do you experience heart palpitations without physical exertion?
7. Do you suffer from heart failure?
8. Do you have high blood pressure?
9. Have you had paralysis (stroke) or speech disorders?
→ Have you had a stroke in the last 6 months?

Nervous System & Respiratory

10. Have you ever fainted during a dental or medical procedure?
11. Do you take medication for epilepsy?
12. Do you suffer from hyperventilation?
13. Do you have asthma?
14. Do you have poor lung function?
15. Do you have hay fever?

Allergies

16. Have you ever had an allergic reaction to medication or medical materials (iodine, rubber, adhesive bandages)?
→ Are you allergic to penicillin or antibiotics?

Metabolism & Internal Organs

17. Do you have diabetes?
18. Have you been diagnosed with an overactive thyroid?
19. Have you been diagnosed with an underactive thyroid?
20. Do you have a liver disease?
21. Do you have a chronic kidney disease for which you follow a special diet?
22. Do you have chronic gastrointestinal complaints causing more than 5 kg of weight loss?
23. Do you currently have a contagious disease? (HIV / HEP A / HEP B / HEP C)
24. Do you have anaemia with symptoms (fatigue, dizziness)?
25. Do you have a malignant disease of the lymph nodes or a blood disorder?
26. Have you been diagnosed with a bleeding tendency?
27. Have you received radiation therapy for a tumour in the head or neck area?

Medication Use

28. Are you currently taking any medication?
→ For the heart?
→ Are you registered with a thrombosis service?
→ For high blood pressure?
→ For diabetes (insulin)?
→ Prednisone, corticosteroids or immunosuppressants?
→ Medication for cancer or bleeding disorders?
→ Penicillin or antibiotics?
→ Sedatives, sleeping pills or antidepressants?

Other medication (specify name)

Do you use recreational drugs daily?

More than 5 alcoholic drinks per day?

Smoking

29. Do you smoke?

If yes, how many cigarettes per day?

Step 2 of 3

Consent form

In accordance with the GDPR and the Dutch BIG Act, we ask you to give consent for the processing of your data.

I give consent for the processing of my personal data and health data as described. (Required)

Practice House Rules

Appointments We work exclusively by appointment. We will always utilise the reserved time scheduled for you. Failure to attend an appointment without timely cancellation (at least 24 hours in advance) may result in being charged for the reserved time.

Pain Complaints / Emergencies For pain complaints, please call before 10:00 AM. We will try to see you the same day. You must accept the offered time slot. You must bring a valid form of identification and proof of health insurance registration.

Payments We have contracts with most health insurers and can bill them directly. If there is a co-payment, you will receive an invoice.

Conduct Aggressive behaviour, verbal or otherwise, will not be tolerated and will result in immediate deregistration. Tandartsenpraktijk Coolhaven is not liable for damage, theft or loss of personal belongings.

I have read the house rules and agree to them. (Required)

Declaration

I declare that I have completed the registration details and the medical questionnaire truthfully. (Required)

I have read and acknowledge the general terms and conditions of Tandartsenpraktijk Coolhaven. (Required)

Date & Digital Signature

Date

City

Digital signature (type your full name)

By entering your name you digitally confirm the above declarations.

* For children under 16, the legal representative must (co-)give consent. In that case, enter the name of the legal representative as the digital signature.

Step 3 of 3

✅

Registration received!

Thank you for registering at Tandartsenpraktijk Coolhaven. We will contact you within one business day to schedule your first appointment.

Do you have urgent questions? Call us at 010 - 203 78 73

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Welcome to
Coolhaven

Your details

Medical history

Consent & Confirmation

Personal details

Insurance

General practitioner & Previous dentist

Financial management

Medical history

Consent form

Registration received!

Your registration

📄 Prefer on paper?

Welcome toCoolhaven

Your details

Medical history

Consent & Confirmation

Personal details

Insurance

General practitioner & Previous dentist

Financial management

Medical history

Consent form

I give Tandartsenpraktijk Coolhaven permission to:

Registration received!

Your registration

📄 Prefer on paper?

Welcome to
Coolhaven