Dentists at Enghave Plads - Patient Health Information

Hint for users of smartphones and tablets: Do not press the Go-button until you have filled in all fields.

Step 1 of 7: Your personal details

Your CPR no.: (*)

Your name: (*)

Your address:

Your profession:

Telephone: (*)

Other telephone:

Telephone (work)

E-mail:

May we send to your e-Boks?

Are you member of "Danmark"? No Yes, in group 1 Yes, in group 2 Yes, in group 5

Member for more than 5 years?

Have you got a dental insurance?

If yes, which one?

Our homepage (www.tep6.dk)

Facebook

Recommended. By whom?

Other

For what reasons are you changing dentists?

How long since your last visit to a dentist?

Do you take medicine? Yes No
If yes, which?

Do you smoke? Yes No
If yes, how much?

Are you pregnant? Yes No

Can you accept anesthesia? Yes No

Do you have diabetes? Yes No

Do you have hypertension? Yes No

Do you have allergies to medicine? Yes No

Do you have hemophilia Yes No

Do you have heart diseases? Yes No

Do you have epilepsy? Yes No

Do you have allergies? Yes No
If yes, which?

Have you got hepatitis? Yes No

Do you have AIDS or are you HIV positive? Yes No

MRSA infection Yes No

Have you got acute tooth problems? Yes No

You now have three choices:

If you click on "Send", your information will be sent to the reception. The receptionist will save the information in your journal.
If you click on "Clear", all entered information will be cleared and you can start all over.
If you click on "To homepage", all entered information will be discarded and you will be directed to the home page of the clinic.