| Name, Surname |
|
|
Are you patient of EDC?
|
Yes
No |
|
Date of your last visit to stomatologist
|
in EDC:
Other: |
|
Contacts (email, phone)
|
|
| Birth date |
|
|
Sex
|
Female
Male |
|
Are you from other country than CR?
|
Yes, from:
No |
|
Your mother tongue
|
English
German
Russian
French
Czech
I also speak:
|
|
Way of payment
|
Insurance:
Other |
|
Acute problems
|
Yes
No |
|
Do you have chronic diseases? (Illnesses of heart, a high blood pressure, thyroid gland, icteric discoloration, allergy, etc.)
|
Yes
No |
|
Medicines you take (including contraception)
|
|
|
Notes
|
|
|
Puprose of visit
|
Other:
|
| Desired date of meeting |
|
|
Own documentation (X-ray analysis)
|
Yes (bring with yourself)
No |
If you have an acute problem, immediately call our 24hrs emergency
on (+420) 224 228 994!
|
|
|
