New patient Form for your AgbZ price comparison



Compare the price with our work inkl. dentist, dental lab-works and implant surgeons in Germany
Free cost - estimate for your dental treatment in Germany. Save up to 60% for a smile "Made in Germany".
Please enter the following information into the form (yellow colored fields), and press the "Submit" button at the bottom of the page.

 Patient-Data: Name, Firstname  Birthday  Email  Phone including country code
               
         
 Payment ?  ZIP-Code:  Town:  Country
    cash     credit card
  		           
 Prices at home: for dentist  for dental lab  for oral surgery  for alloys or metal-free
               
 My problem. Or how can we help you ?

   
 

 

 

   MY DENTAL CHART

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Dental History


Are you presently having dental pain?
Yes
No
Have you had orthodontic treatment:
Yes
No
Do your gums bleed when brushing your teeth?
Yes
No
Have you ever been told you have pyorrhea (gum disease)?
Yes
No
Have you ever had any gum treatments?
Yes
No
Have you ever had professional instructions on dental home care?
Yes
No
Do you have any pain or soreness around the eyes or ears?
Yes
No
Do you have any unpleasant odor or taste in your mouth
Yes
No
Do you always have something to be treated or repaired when you visit a dentist?
Yes
No
Do you feel that in the past you have required a lot of dental work?
Yes
No
If yes, was it to replace previous dentistry?
Yes
No
Do you wish to talk with the dentist privately about any problem?
Yes
No

 

Have you ever had any of the following


Allergies
Arthritis, Gout or sore joints
Artificial joint replacement
Blood trouble, anemia, leukemia
Chest pain, pressure or tightness
Cancer
Diabetes
Excessive bleeding
Fainting, convulsions, epilepsy
Glaucoma
Headaches when lying down
Heart attack
Heart murmur
Hepatitis, liver desiease, jaundice
High blood pressure
History of drug or alcohol abuse
Lung Trouble (TB, asthma, emphysema)
Mitral valve prolapse
Nervous breakdown, psychotherapy
Positive HIV test
Radiation treatments
Rheumatic fever
Shortness of breath
Swelling of ankles or feet
VD (syphillis, gonorrhea, etc.)
Problems with recreational drugs
Problems with local anesthesia
I'm pregnant, or trying to get
I'm nursing a baby
I'm using birth control pills or patches


 Additional comments


 
Do you have any other problems that we should know about?
Do you have any additional concerns or comments ?

 
Data agreement: I agree, that this form in facts can be used for a price comparison and dentist search in Germany.