Appointment & registration

Last name*

First name*

Date of birth*

For children and adolescents, last name and first name of parent

Post code/town

Personal telephone*

Work telephone

Your email address*

How would you like to be contacted?
—Bitte wähle eine Option—By phoneBy email

Message

Information about the patient

Please choose age*< 12 years12 - 18 years> 18 years

Parent/Legal guardian (if required)

Information about the treatment

—Bitte wähle eine Option—Please send me informationI do not need information

Following documents are already available

—Bitte wähle eine Option—Dental X-RayOPTCeph X-RayModels

Appointment: Unless requested otherwise, patients will be contacted by us directly

—Bitte wähle eine Option—UrgentNo hurryPlease contact