NEW PATIENT REGISTRATION FORM

FORMULARIO DE INSCRIPCION

Patient information Anmeldeformular


List ALL Medications:-

List ALL Allergies:-

YesNo

Le informamos que los datos personales facilitados se incorporarán en un Fichero de responsabilidad de Adnan Kaiserimam. Estos podrán ser comunicados y/o cedidos a terceros, como profesionales odontólogos y protésicos dentales, en aquellos casos en que sea necesario. Por favor marcar la casilla en función de si desea o no que esto ocurra:
SINO
Podrá ejercitar su derecho de acceso, rectificación, oposición y cancelación enviando un correo a reception@tl-dc.com Si desea más información respecto a la Cesión de Datos por favor visitar nuestra página web: https://thelondondentalclinic.com
We inform you that the personal data provided will be included in a File of responsibility of Adnan Kaiserimam. These may be communicated and / or transferred to third parties, such as dental professionals and dental prosthetics, in those cases where necessary. Please check the box depending on whether or not you want this to happen:
YesNO
You can exercise your right of access, rectification, opposition and cancellation by sending an email to reception@tl-dc.com If you want more information regarding the Data transfer please visit our website: https://thelondondentalclinic.com

IMPORTANT INFORMATION PLEASE READ
Missed appointments may result in a 25€ penalty. / Las citas perdidas pueden resultar en una multa de 25€. / Versäumte Termine können mit 25€ Euro Strafe geahndet werden.
All new patients at their first appointment will be requested to make the online deposit payment to secure any booking. Any failure to make the deposit payment can result in the appointment being cancelled.
At the LDC we adopt a zero tolerance to disrespectful behaviour. Should any patient wish to discuss their treatment or indeed make any complaint they are encouraged to contact the clinic manager directly in writing by email ian@tl-dc.com. Thank you for your consideration.


Firma del Paciente / Patient Signature / Unterschrift des Patienten :