Patient Medical History

Dear patient,

Welcome to the office of Dr. Mártyán.

In order to be able to treat you optimally, please fill out this medical history form carefully and inform us immediately if there are any changes. Thank you very much!!

1Master Data > 2Medical Data > 3Information
Patient data

The following section concerns the patient's data. If the patient is co-insured, the insured person data can be entered in the next section.
Patientennummer
DentNr
Titel
Titel hinten
Given Name
Surname
Birth date Birth date / TT / MM JJJJ
Social insurance number
Muss 10 ziffern. Soeben eingegeben: 0 ziffern.
Bitte geben Sie ihre 10-stellige Versicherungsnummer ein.
Social insurance company
Adress
Street / House no.
Zip code
Höchstens 9 zeichen erlaubt. Soeben eingegeben: 0 zeichen.
City
Country
Email adress
Mobile phone
Private phone
Business phone
The patient is

The patient is self-insured co-insured
Insured person

If the patient is co-insured, the data of the insured person can be entered here.
Insured title
Vers. Titel hinten
Insured given name
Insured surname
Insured date of birth Insured date of birth / TT / MM JJJJ
Insured social insurance number
Muss 10 ziffern. Soeben eingegeben: 0 ziffern.
Relationship
Address as above?

Address as above? Yes different adress
Insured Adress
Street / House no.
Zip code
Höchstens 9 zeichen erlaubt. Soeben eingegeben: 0 zeichen.
City
Country
Employer

Details of the employer of the patient/insured person
Name of employer
Dienstgeber Adresse
Dienstgeber Straße / HausNr.
Dienstgeber PLZ
Höchstens 9 zeichen erlaubt. Soeben eingegeben: 0 zeichen.
Dienstgeber Ort
Dienstgeber Land
Profession
Dienstgeber Telefonnummer

Patient Medical History

Patient Medical History

Patient data

Adress

Insured person

Insured Adress

Employer

Dienstgeber Adresse