Dental Intake

Personal Data

First name

Last name

Date of birth

Gender

Phone

Address

Postal code

City

Country

Occupation

Insurance provider

Insurance type

Public insurance Private insurance - non basic tariff Private insurance - basic tariff Civil servant aid eligible

Patient and payer are different

Payer name

Payer date of birth

Payer address

Postal code

City

Emergency contact name

Emergency contact phone

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Who referred you to us?