Health Declaration

We kindly request you to complete the questionnaire below. It is essential to both, you and us, that the dentist is fully informed about your health condition. The answers will be treated discreetly as we abide by the duty of medical confidentiality. 


Your oral health can be (strongly) influenced by several diseases and the use of certain medications. Therefore, your dentist must take this into account when devising an appropriate treatment plan.


Should you have any problems completing this Health Declaration questionnaire, you have the option to complete it together with the care consultant at the clinic before the intake interview. Please let us know in time to plan this and send your e-mail request to:

Health Declaration Form