Practice for Biological & General Dentistry - Amsterdam/Osdorp since 1983
020 610 2883
Amalgam (silver) Fillings Fact page
FAQ – Payment / Insurance
FAQ – Treatments
Step 1 of 5
Date of birth:
ZIP / Postal Code
Dutch social security number.
Basic Health Insurer
Your number at your insurer
Are you insured for dental costs?
With the same insurer as above?
If no, what is the name and policy number of your dental insurer?
What is your maximum coverage for dental per year?
Questions about your dental history:
When was your last visit to the dentist?
First visit to the dentist
Less than 6 months ago
Less than a year ago
Less than 2 years ago
More than 2 years ago
More than 5 years ago
What treatment was done?
Why did you leave your last dentist?
Have you ever been to dental hygienist for treatment?
Why did you choose to come to Tandarts Praktijk René (You can check more than one answer)*
Haven't been to dentist for a long time
I have pain
I would like a biological dentist
Problems with dentures
Unhappy with teeth
Other: (fill in below)
How did you find out about our practice?
Tandarts.nl or another on-line dentist search engine
Amalgaam Vrij Nederland website
Waled past the practice
Sent by a Dr. of therapist
Recommendation by a friend or family member
Are you happy with the current condition of your teeth?
Do you have problems with your teeth or gums?
If yes can you briefly state the problem/s?
Are your teeth sensistive to:
Chewing or biting?
Do you have bleeding gums?
Do you have loose teeth?
How often do you brush your teeth per day?
3x or more
Do you smoke?
Are there things we should be aware of?
What do you find important in your relationship with your dentist?
Do you have any other requests or questions?
Do you have a preference for a dentist in our practice? If so, which one?
René van der Bijl
Alja de Graaff
Do you want to register other family members? If so, could you write their names, dates of birth, and social security number here?