Empfangsbereich der Zahnarztpraxis Dr. Staubach in Hannover Döhren
Registration sheet

Registration form

Deutsch
Deutsch
English
English

Please only fill out the registration form after making an appointment.

For appointment requests / arrangements, please call us: 0511 123 75 00

Your appointment

Patient

Main insured

(fill in only if not at the same time patient)

Health profile

Dental history

I ask you, in your own interest, to inform us immediately of any change in your state of health.

For our patients:
Please inform us immediately if you are pregnant!

You've finally made it!

Thank you again for answering all the questions so carefully. If filling in the sheet has any problems, do not hesitate to contact us. That's what we're here for you.

I agree that my details from the contact form will be collected and processed to answer my request. The data will be deleted after your request has been processed. Note: You can revoke your consent at any time for the future by e-mail to info@drstaubach.de. Detailed information on the handling of user data can be found in our privacy policy.