{"id":16973,"date":"2026-06-05T10:37:36","date_gmt":"2026-06-05T10:37:36","guid":{"rendered":"https:\/\/www.dr-worseck.de\/form\/"},"modified":"2026-10-27T17:19:47","modified_gmt":"2026-10-27T17:19:47","slug":"form","status":"publish","type":"page","link":"https:\/\/www.dr-worseck.de\/en\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"16973\" class=\"elementor elementor-16973 elementor-14899\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3dccc39 e-flex e-con-boxed parallax_section_no qode_elementor_container_no e-con e-parent\" data-id=\"3dccc39\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-01d6d26 elementor-widget elementor-widget-text-editor\" data-id=\"01d6d26\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Dear Parents,<br\/>Since we hope to accompany your child for many years, we want to work together from the very beginning to spark your child&#8217;s curiosity and make dental visits as positive as possible. Children are truly bright: if a reward is promised for cooperating, they automatically understand that there is a hurdle to overcome, and that is exactly what can trigger anxiety in the first place. Therefore, please refrain from promising rewards as well as using phrases like \u201cdon&#8217;t be afraid\u201d or \u201cit won&#8217;t hurt.\u201d<br\/><br\/>Please let us take the lead in communicating with your child, and feel free to encourage them to go into the treatment room with us alone. Please consider whether you wish to accompany your child into the room or encourage them to go alone; it is usually more successful when anxious parents stay outside. We respond to your child&#8217;s wishes in a completely child-friendly manner.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-38ab977f e-flex e-con-boxed parallax_section_no qode_elementor_container_no e-con e-parent\" data-id=\"38ab977f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-525d5c11 elementor-widget elementor-widget-text-editor\" data-id=\"525d5c11\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t\n<div class=\"wp-block-columns tab_form_section\">\n<div class=\"wp-block-column\">\n<div class=\"wp-block-columns\">\n<div class=\"wp-block-column\">\n<div class=\"wp-block-qi-blocks-tabs-horizontal qodef-block-container qodef-block-0014e7d3\">\n<div class=\"qi-block-tabs-horizontal qodef-block qodef-m qodef-layout--simple qodef-title-hover--underline-draw qodef-title-underline-from-left\">\n<ul class=\"qodef-tabs-horizontal-navigation\">\n<li>\n<h5 class=\"qodef-tab-title\"><a href=\"#qodef-tab-0014e7d30\"><span class=\"q-text\">MEDICAL HISTORY FORM<\/span><\/a><\/h5>\n<\/li>\n<li>\n<h5 class=\"qodef-tab-title\"><a href=\"#qodef-tab-0014e7d31\"><span class=\"q-text\">CHILDREN&#8217;S MEDICAL HISTORY FORM<\/span><\/a><\/h5>\n<\/li>\n<\/ul>\n<div id=\"qodef-tab-0014e7d30\" class=\"qodef-tabs-horizontal-content\">\n<div class=\"top-bar\">\n<div class=\"page-title\">Download Offline Application Form of <span data-teams=\"true\">Medical history form for printing<\/span><\/div>\n<div class=\"top-buttons\"><a class=\"btn print-btn\" href=\"https:\/\/www.dr-worseck.de\/wp-content\/uploads\/2026\/10\/Erwachsene_Juliane_Worseck.pdf\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"download_icon\" src=\"https:\/\/www.dr-worseck.de\/wp-content\/uploads\/2026\/07\/download.png\"\/>Download PDF<\/a><\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f17208-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"17208\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/16973#wpcf7-f17208-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"17208\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.2.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f17208-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:17208,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;gefunden-pers\\u00f6nliche&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;gefunden&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;pers\\u00f6nliche Empfehlung&quot;}]},{&quot;then_field&quot;:&quot;kuenstliches-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;kuenstliches-gelenk&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ja&quot;}]},{&quot;then_field&quot;:&quot;schwangerschaft-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;schwangerschaft&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ja&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;}}\" \/>\n<\/fieldset>\n<div class=\"anamnese-form\">\n\n  <div class=\"form-intro\">\n    <h2 class=\"form-title\">MEDICAL HISTORY FORM<\/h2>\n    <p class=\"form-subtitle\">Welcome to our practice!<\/p>\n    <p class=\"form-subtitle\">Before we take the time to discuss your wishes and concerns, we need your personal details as well as information about your general health. This is important to ensure that your treatment is appropriate and carries as little risk as possible. All information you provide is subject to medical confidentiality.<\/p>\n  <\/div>\n\n  <!-- ============ SECTION 1: PERSONAL INFORMATION ============ -->\n\n  <div class=\"form-section section-personal\">\n    <h3 class=\"section-title\">Personal Information<\/h3>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"your-name\">Last Name, First Name <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"your-name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"geburtsdatum\">Date of Birth <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"geburtsdatum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"geburtsdatum\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"strasse\">Street, House Number <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"strasse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"strasse\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"strasse\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"plz-ort\">Postal Code \/ City <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"plz-ort\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"plz-ort\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plz-ort\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"telefon\">Telephone <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"telefon\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"mobil\">Mobile Phone <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"mobil\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"mobil\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mobil\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"your-email\">Email Address <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" id=\"your-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"beruf\">Occupation <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"beruf\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"beruf\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"beruf\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"betreuer-name\">Legal Guardian (if applicable)<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"betreuer-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"betreuer-name\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"betreuer-name\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label>Insurance Status <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"versicherung\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"versicherung[]\" value=\"Statutory\" \/><span class=\"wpcf7-list-item-label\">Statutory<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"versicherung[]\" value=\"Statutory + Supplementary Insurance\" \/><span class=\"wpcf7-list-item-label\">Statutory + Supplementary Insurance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"versicherung[]\" value=\"Private\" \/><span class=\"wpcf7-list-item-label\">Private<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"versicherung[]\" value=\"Civil Service Subsidy (Beihilfe)\" \/><span class=\"wpcf7-list-item-label\">Civil Service Subsidy (Beihilfe)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"versicherung[]\" value=\"Basic Tariff\" \/><span class=\"wpcf7-list-item-label\">Basic Tariff<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"krankenkasse\">Health Insurance Provider \/ Payer <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"krankenkasse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"krankenkasse\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"krankenkasse\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"zusatzversicherung\">Supplementary Insurance<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"zusatzversicherung\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"zusatzversicherung\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zusatzversicherung\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label>How Did You Find Us? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"gefunden\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Personal Recommendation\" \/><span class=\"wpcf7-list-item-label\">Personal Recommendation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Google\" \/><span class=\"wpcf7-list-item-label\">Google<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Website\" \/><span class=\"wpcf7-list-item-label\">Website<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Instagram\" \/><span class=\"wpcf7-list-item-label\">Instagram<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Jameda\" \/><span class=\"wpcf7-list-item-label\">Jameda<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n<div data-id=\"gefunden-pers\u00f6nliche\" data-orig_data_id=\"gefunden-pers\u00f6nliche\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"gefunden-von\">If recommended, by whom? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"gefunden-von\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"gefunden-von\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gefunden-von\" \/><\/span>\n  <\/div>\n<\/div>\n\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 2: REASON FOR VISIT ============ -->\n\n  <div class=\"form-section section-reason\">\n\n<h3 class=\"section-title\">Reason for Today&#8217;s Visit<span class=\"con_req\">*<\/span><\/h3>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"besuchsgrund\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Routine Check-up\" \/><span class=\"wpcf7-list-item-label\">Routine Check-up<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Preventive Care\" \/><span class=\"wpcf7-list-item-label\">Preventive Care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Pain\" \/><span class=\"wpcf7-list-item-label\">Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Gum Problems\" \/><span class=\"wpcf7-list-item-label\">Gum Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Dental Prosthetics\" \/><span class=\"wpcf7-list-item-label\">Dental Prosthetics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Aesthetics\" \/><span class=\"wpcf7-list-item-label\">Aesthetics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Jaw Joint Problems\" \/><span class=\"wpcf7-list-item-label\">Jaw Joint Problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Snoring\" \/><span class=\"wpcf7-list-item-label\">Snoring<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Adult Orthodontics\" \/><span class=\"wpcf7-list-item-label\">Adult Orthodontics<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Second Opinion\" \/><span class=\"wpcf7-list-item-label\">Second Opinion<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 3: DENTAL MEDICAL HISTORY (TABLE LAYOUT) ============ -->\n\n  <div class=\"form-section section-dental-history\">\n\n<h3 class=\"section-title\">Dental Medical History<\/h3>\n\n<div class=\"main_table_container\">\n\n  <table class=\"anamnese-table\">\n\n    <thead>\n      <tr>\n        <th colspan=\"2\" class=\"col-frage\">Question<\/th>\n      <\/tr>\n    <\/thead>\n\n    <tbody>\n\n      <tr>\n        <td>Are you currently experiencing toothache? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zahnschmerzen\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnschmerzen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnschmerzen\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you have bleeding gums or other gum problems? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zahnfleischbluten\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnfleischbluten\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnfleischbluten\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Does your jaw joint click when you chew or yawn? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"kiefergelenk-knacken\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"kiefergelenk-knacken\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"kiefergelenk-knacken\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you suffer from headaches or neck pain? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"kopf-nackenschmerzen\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"kopf-nackenschmerzen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"kopf-nackenschmerzen\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you snore? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"schnarchen-frage\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"schnarchen-frage\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"schnarchen-frage\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Are you satisfied with the appearance of your teeth? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zufrieden-aussehen\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zufrieden-aussehen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zufrieden-aussehen\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you regularly receive professional dental cleanings? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zahnreinigung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnreinigung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnreinigung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you use dental floss or interdental brushes? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zahnseide\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnseide\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnseide\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Has your health changed in the past year? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheitszustand-veraendert\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gesundheitszustand-veraendert\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gesundheitszustand-veraendert\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Are you currently receiving medical treatment? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"aerztliche-behandlung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"aerztliche-behandlung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"aerztliche-behandlung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>If you are receiving medical treatment, what is the reason? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"behandlung-warum\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"behandlung-warum\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"behandlung-warum\" \/><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Regular Medications <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"medikamente\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"medikamente\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medikamente\" \/><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>General Practitioner \/ Specialist <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"hausarzt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"hausarzt\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hausarzt\" \/><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Allergies \/ Intolerances (e.g. penicillin, latex, metals)? <span class=\"con_req\">*<\/span><\/td>\n        <td>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"allergien\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergien\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergien\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"allergien-details\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"allergien-details\" aria-invalid=\"false\" placeholder=\"Please provide details...\" value=\"\" type=\"text\" name=\"allergien-details\" \/><\/span>\n        <\/td>\n      <\/tr>\n\n    <\/tbody>\n\n  <\/table>\n\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 4: DENTAL HISTORY ============ -->\n\n  <div class=\"form-section section-dental-past\">\n\n<h3 class=\"section-title\">Previous Dental History<\/h3>\n\n<div class=\"main_table_container\">\n\n  <table class=\"anamnese-table\">\n\n    <thead>\n      <tr>\n        <th colspan=\"2\" class=\"col-frage\">Question<\/th>\n      <\/tr>\n    <\/thead>\n\n    <tbody>\n\n      <tr>\n        <td>Have you had any X-rays taken in the past two years? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"roentgen\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"roentgen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"roentgen\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Have you ever experienced problems with local anaesthesia? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"probleme-betaeubung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"probleme-betaeubung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"probleme-betaeubung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Do you currently have any dental prostheses? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"zahnersatz-letzte-2-jahre\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnersatz-letzte-2-jahre\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnersatz-letzte-2-jahre\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>If yes, please briefly explain \/ specify when: <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"vorgeschichte-erlaeuterung\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"vorgeschichte-erlaeuterung\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vorgeschichte-erlaeuterung\" \/><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Other Information About Your Dental History <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"sonstige-informationen\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" id=\"sonstige-informationen\" aria-required=\"true\" aria-invalid=\"false\" name=\"sonstige-informationen\"><\/textarea><\/span><\/td>\n      <\/tr>\n\n    <\/tbody>\n\n  <\/table>\n\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 5: GENERAL HEALTH (TABLE LAYOUT, 2-COLUMN PAIRED) ============ -->\n\n  <div class=\"form-section section-general-health\">\n\n<h3 class=\"section-title\">General Health<\/h3>\n\n<p class=\"section-note\">Do you have any of the following medical conditions or health-related issues?<\/p>\n\n<div class=\"main_table_container\">\n\n  <table class=\"anamnese-table condition-table\">\n\n    <thead>\n      <tr>\n        <th colspan=\"2\" class=\"col-frage\">Medical Condition \/ Health Issue<\/th>\n        <th colspan=\"2\" class=\"col-frage\">Medical Condition \/ Health Issue<\/th>\n      <\/tr>\n    <\/thead>\n\n    <tbody>\n\n      <tr>\n        <td>Pacemaker <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"herzschrittmacher\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"herzschrittmacher\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"herzschrittmacher\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Artificial Joint <span class=\"con_req\">*<\/span>\n          <div data-id=\"kuenstliches-yes\" data-orig_data_id=\"kuenstliches-yes\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"gelenk-seit-wann\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"gelenk-seit-wann\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Since when?\" value=\"\" type=\"text\" name=\"gelenk-seit-wann\" \/><\/span>\n          <\/div>\n        <\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"kuenstliches-gelenk\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"kuenstliches-gelenk\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"kuenstliches-gelenk\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Heart Failure <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"herzinsuffizienz\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"herzinsuffizienz\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"herzinsuffizienz\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Heart Rhythm Disorder <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"herzrhythmusstoerung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"herzrhythmusstoerung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"herzrhythmusstoerung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>High Blood Pressure <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"bluthochdruck\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bluthochdruck\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bluthochdruck\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Heart Attack <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"herzinfarkt\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"herzinfarkt\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"herzinfarkt\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Diabetes <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"diabetes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Blood Thinners <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"blutverduenner\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"blutverduenner\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"blutverduenner\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Osteoporosis <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"osteoporose\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"osteoporose\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"osteoporose\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Rheumatism <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"rheuma\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rheuma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rheuma\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Glaucoma <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"glaukom\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"glaukom\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"glaukom\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Epilepsy <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsie\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"epilepsie\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"epilepsie\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Asthma <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"asthma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"asthma\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Chronic Immune Deficiency <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"immunschwaeche\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"immunschwaeche\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"immunschwaeche\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Hepatitis <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"hepatitis\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"hepatitis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"hepatitis\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Depression <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"depressionen\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"depressionen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"depressionen\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Blood Clotting Disorder <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"blutgerinnungsstoerung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"blutgerinnungsstoerung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"blutgerinnungsstoerung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Bulimia \/ Eating Disorder <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"essstoerung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"essstoerung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"essstoerung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Stroke <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"schlaganfall\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"schlaganfall\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"schlaganfall\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n        <td>Bisphosphonate Use <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"bisphosphonate\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bisphosphonate\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bisphosphonate\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n    <\/tbody>\n\n  <\/table>\n\n<\/div>\n\n<div class=\"main_table_container main_new_contain\">\n\n  <div class=\"form-row\">\n    <div class=\"form-label\">Pregnancy? <span class=\"con_req\">*<\/span><\/div>\n    <div class=\"form-field\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"schwangerschaft\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"schwangerschaft\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"schwangerschaft\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n      <div data-id=\"schwangerschaft-yes\" data-orig_data_id=\"schwangerschaft-yes\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"schwangerschaft-monat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"schwangerschaft-monat\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Month\" value=\"\" type=\"text\" name=\"schwangerschaft-monat\" \/><\/span>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"form-row\">\n    <div class=\"form-label\">Smoking? <span class=\"con_req\">*<\/span><\/div>\n    <div class=\"form-field\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"rauchen\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rauchen\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rauchen\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"rauchen-wie-viele\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"rauchen-wie-viele\" aria-invalid=\"false\" placeholder=\"How many?\" value=\"\" type=\"text\" name=\"rauchen-wie-viele\" \/><\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"form-row\">\n    <div class=\"form-label\">Other Important Health Information<\/div>\n    <div class=\"form-field\">\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gesundheit-weitere-informationen\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"gesundheit-weitere-informationen\" aria-invalid=\"false\" name=\"gesundheit-weitere-informationen\"><\/textarea><\/span>\n    <\/div>\n  <\/div>\n\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 6: CONSENTS ============ -->\n\n  <div class=\"form-section section-consent\">\n\n<h3 class=\"section-title\">Consents and Administrative Information<span class=\"con_req\">*<\/span><\/h3>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"recall\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"recall[]\" value=\"I would like to receive reminders for my routine check-ups and preventive care appointments (recall service).\" \/><span class=\"wpcf7-list-item-label\">I would like to receive reminders for my routine check-ups and preventive care appointments (recall service).<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"terminbestaetigung\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"terminbestaetigung[]\" value=\"I agree to receive appointment confirmations and administrative information by telephone, SMS or email.\" \/><span class=\"wpcf7-list-item-label\">I agree to receive appointment confirmations and administrative information by telephone, SMS or email.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"datenweitergabe\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"datenweitergabe[]\" value=\"I consent to the legally permitted sharing of my treatment data with other healthcare professionals involved in my care, dental laboratories, billing offices and other legally authorised recipients.\" \/><span class=\"wpcf7-list-item-label\">I consent to the legally permitted sharing of my treatment data with other healthcare professionals involved in my care, dental laboratories, billing offices and other legally authorised recipients.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"datenschutz\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"datenschutz[]\" value=\"I have received or read the privacy information provided in accordance with Article 13 of the GDPR.\" \/><span class=\"wpcf7-list-item-label\">I have received or read the privacy information provided in accordance with Article 13 of the GDPR.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"vollstaendigkeit\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"vollstaendigkeit[]\" value=\"I confirm that the information I have provided is complete and accurate.\" \/><span class=\"wpcf7-list-item-label\">I confirm that the information I have provided is complete and accurate.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 7: CANCELLATIONS \/ MISSED APPOINTMENT FEE ============ -->\n\n  <div class=\"form-section section-policy\">\n\n<h3 class=\"section-title\">Appointment Cancellation \/ Missed Appointment Fee<\/h3>\n\n<p class=\"policy-text\">\n  &#8220;Our practice operates on an appointment-only basis. If you are unable to attend your appointment, please cancel at least 24 hours in advance. A missed appointment fee will be charged for cancellations and missed appointments, regardless of the reason. We make every effort to fill any appointment slots that become available at short notice with patients from our waiting list. If we are successful, no missed appointment fee will, of course, be charged.&#8221;\n<\/p>\n\n  <\/div>\n\n  <!-- ============ SECTION 8: CONFIRMATION \/ SIGNATURE ============ -->\n\n  <div class=\"form-section section-signature\">\n\n<div class=\"field-row two-col\">\n\n  <div class=\"field-group\">\n    <label for=\"ort-datum\">Place, Date <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"ort-datum\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"ort-datum\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Place, Date\" value=\"\" type=\"text\" name=\"ort-datum\" \/><\/span>\n  <\/div>\n\n  <div class=\"field-group\">\n    <label for=\"unterschrift\">Patient&#8217;s Signature <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"unterschrift\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"unterschrift\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Digital Signature \/ Name\" value=\"\" type=\"text\" name=\"unterschrift\" \/><\/span>\n  <\/div>\n\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"unterschrift-vertreter\">Legal Guardian&#8217;s Signature (for minors)<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"unterschrift-vertreter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"unterschrift-vertreter\" aria-invalid=\"false\" placeholder=\"Digital Signature \/ Guardian&#039;s Name\" value=\"\" type=\"text\" name=\"unterschrift-vertreter\" \/><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <div class=\"form-submit\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n  <\/div>\n\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"123\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<div id=\"qodef-tab-0014e7d31\" class=\"qodef-tabs-horizontal-content\">\n<div class=\"top-bar\">\n<div class=\"page-title\">Download Offline Application Form of <span data-teams=\"true\">Children&#8217;s medical history form for printing<\/span><\/div>\n<div class=\"top-buttons\"><a class=\"btn print-btn\" href=\"https:\/\/www.dr-worseck.de\/wp-content\/uploads\/2026\/10\/Anamnesebogen-Praxis-Dr.-Worseck-4.pdf\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"download_icon\" src=\"https:\/\/www.dr-worseck.de\/wp-content\/uploads\/2026\/07\/download.png\"\/>Download PDF<\/a><\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f17207-o2\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"17207\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/16973#wpcf7-f17207-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"17207\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.2.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f17207-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:17207,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;fluoridtabletten-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;fluoridtabletten&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ja&quot;}]},{&quot;then_field&quot;:&quot;gestillt-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;gestillt&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Ja&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;}}\" \/>\n<\/fieldset>\n<div class=\"anamnese-form\">\n\n  <div class=\"form-intro\">\n    <h2 class=\"form-title\">CHILDREN&#8217;S MEDICAL HISTORY FORM<\/h2>\n    <p class=\"form-subtitle\">Dear Parents, a thorough medical history is essential for properly preparing for and providing subsequent treatment for your child at our practice. Please take your time to complete this form fully and carefully.<\/p>\n  <\/div>\n\n  <!-- ============ SECTION 1: PERSONAL INFORMATION ============ -->\n\n  <div class=\"form-section section-personal\">\n    <h3 class=\"section-title\">Personal Information<\/h3>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"kind-name\">Child (Last Name, First Name): <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"kind-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"kind-name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kind-name\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"versicherter-name\">Insured Person (Name): <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"versicherter-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"versicherter-name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"versicherter-name\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"kind-geburtsdatum\">Date of Birth: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"kind-geburtsdatum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"kind-geburtsdatum\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"kind-geburtsdatum\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"versicherter-geburtsdatum\">Date of Birth: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"versicherter-geburtsdatum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" id=\"versicherter-geburtsdatum\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"versicherter-geburtsdatum\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"anschrift-strasse\">Street Address: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"anschrift-strasse\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"anschrift-strasse\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"anschrift-strasse\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"erziehungsberechtigte-1\">Parent \/ Legal Guardian: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"erziehungsberechtigte-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"erziehungsberechtigte-1\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"erziehungsberechtigte-1\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"plz-ort\">Postal Code \/ City: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"plz-ort\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plz-ort\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"kontakt-1\">Mobile Phone \/ Email: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"kontakt-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"kontakt-1\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kontakt-1\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"erziehungsberechtigte-2\">Parent \/ Legal Guardian:<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"erziehungsberechtigte-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"erziehungsberechtigte-2\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"erziehungsberechtigte-2\" \/><\/span>\n  <\/div>\n  <div class=\"field-group\">\n    <label for=\"kontakt-2\">Mobile Phone \/ Email:<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"kontakt-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"kontakt-2\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kontakt-2\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label>Insurance: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"versicherung\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"versicherung\" value=\"Statutory\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Statutory<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"versicherung\" value=\"Statutory with supplementary insurance\" \/><span class=\"wpcf7-list-item-label\">Statutory with supplementary insurance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"versicherung\" value=\"Private\" \/><span class=\"wpcf7-list-item-label\">Private<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"versicherung\" value=\"Civil service subsidy (Beihilfe)\" \/><span class=\"wpcf7-list-item-label\">Civil service subsidy (Beihilfe)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"versicherung\" value=\"Basic tariff\" \/><span class=\"wpcf7-list-item-label\">Basic tariff<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label>How did you hear about us? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"gefunden\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Recommendation\" \/><span class=\"wpcf7-list-item-label\">Recommendation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Google\" \/><span class=\"wpcf7-list-item-label\">Google<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Website\" \/><span class=\"wpcf7-list-item-label\">Website<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Instagram\" \/><span class=\"wpcf7-list-item-label\">Instagram<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Jameda\" \/><span class=\"wpcf7-list-item-label\">Jameda<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"gefunden[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 2: WHY ARE YOU VISITING US? ============ -->\n\n  <div class=\"form-section section-reason\">\n    <h3 class=\"section-title\">Why Are You Visiting Us?<span class=\"con_req\">*<\/span><\/h3>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"besuchsgrund\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Initial examination\" \/><span class=\"wpcf7-list-item-label\">Initial examination<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Check-up\" \/><span class=\"wpcf7-list-item-label\">Check-up<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Preventive dental care\" \/><span class=\"wpcf7-list-item-label\">Preventive dental care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Pain\" \/><span class=\"wpcf7-list-item-label\">Pain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Dental injury\" \/><span class=\"wpcf7-list-item-label\">Dental injury<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Second opinion\" \/><span class=\"wpcf7-list-item-label\">Second opinion<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"besuchsgrund[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n  <!-- ============ SECTION 3: GENERAL INFORMATION (TABLE LAYOUT) ============ -->\n\n  <div class=\"form-section section-general-info\">\n    <h3 class=\"section-title\">General Information<\/h3>\n\n<div class=\"main_table_container\">\n  <table class=\"anamnese-table\">\n    <thead>\n      <tr>\n        <th colspan=\"2\" class=\"col-frage\">Question<\/th>\n      <\/tr>\n    <\/thead>\n    <tbody>\n      <tr>\n        <td>Is this your child&#8217;s first dental visit? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"erster-besuch\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"erster-besuch\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"erster-besuch\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n      <tr>\n        <td>Has your child received dental treatment before? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"bereits-behandelt\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bereits-behandelt\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bereits-behandelt\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n      <tr>\n        <td>Have there been any problems with local anaesthesia? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"probleme-betaeubung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"probleme-betaeubung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"probleme-betaeubung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n      <tr>\n        <td>Are there any special considerations regarding your child&#8217;s interactions with doctors or medical treatments? <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"besonderheiten-arztumgang\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"besonderheiten-arztumgang\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"besonderheiten-arztumgang\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n    <\/tbody>\n  <\/table>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"individuelle-antworten\">Additional Comments:<\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"individuelle-antworten\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"individuelle-antworten\" aria-invalid=\"false\" placeholder=\"Enter your notes here...\" name=\"individuelle-antworten\"><\/textarea><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 4: ORAL HYGIENE ============ -->\n\n  <div class=\"form-section section-zahnpflege\">\n    <h3 class=\"section-title\">Oral Hygiene<\/h3>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"putzen-haeufigkeit\">How Often Does Your Child Brush Their Teeth? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"putzen-haeufigkeit\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" id=\"putzen-haeufigkeit\" min=\"0\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Times per day\" value=\"\" type=\"number\" name=\"putzen-haeufigkeit\" \/><\/span>\n  <\/div>\n\n  <div class=\"field-group\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"putzen-wer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"putzen-wer\" value=\"Independently\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Independently<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"putzen-wer\" value=\"With assistance\" \/><span class=\"wpcf7-list-item-label\">With assistance<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"putzen-wer\" value=\"Parents only\" \/><span class=\"wpcf7-list-item-label\">Parents only<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"zahnpasta\">Which Toothpaste Does Your Child Use? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"zahnpasta\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"zahnpasta\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zahnpasta\" \/><\/span>\n  <\/div>\n\n  <div class=\"field-group\">\n    <label>Does Your Child Clean Between Their Teeth? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"zahnzwischenraum-unterstuetzung\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"zahnzwischenraum-unterstuetzung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"zahnzwischenraum-unterstuetzung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row two-col\">\n  <div class=\"field-group\">\n    <label for=\"andere-hilfsmittel\">Other Oral Hygiene Aids? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"andere-hilfsmittel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"andere-hilfsmittel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"andere-hilfsmittel\" \/><\/span>\n  <\/div>\n\n  <div class=\"field-group\">\n    <label>Regular Preventive Dental Care \/ Professional Teeth Cleaning? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"individualprophylaxe\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"individualprophylaxe\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"individualprophylaxe\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n\n<p class=\"section-note\">Fluoride Use:<\/p>\n\n<div class=\"flu_main\">\n\n  <div class=\"field-row two-col\">\n    <div class=\"field-group\">\n      <label>Fluoride Tablets: <span class=\"con_req\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"fluoridtabletten\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"fluoridtabletten\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"fluoridtabletten\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n    <\/div>\n\n    <div data-id=\"fluoridtabletten-yes\" data-orig_data_id=\"fluoridtabletten-yes\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n    <div class=\"field-group\">\n      <label for=\"fluoridtabletten-dauer\">Duration: <span class=\"con_req\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"fluoridtabletten-dauer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"fluoridtabletten-dauer\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fluoridtabletten-dauer\" \/><\/span>\n    <\/div>\n    <\/div>\n  <\/div>\n\n\n  <div class=\"field-row\">\n    <div class=\"field-group half-width\">\n      <label>Fluoridated Table Salt: <span class=\"con_req\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"fluoridiertes-speisesalz\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"fluoridiertes-speisesalz\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"fluoridiertes-speisesalz\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n    <\/div>\n  <\/div>\n\n\n  <div class=\"field-row two-col\">\n    <div class=\"field-group\">\n      <label>Was Your Child Breastfed? <span class=\"con_req\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gestillt\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gestillt\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gestillt\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n    <\/div>\n\n    <div data-id=\"gestillt-yes\" data-orig_data_id=\"gestillt-yes\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n    <div class=\"field-group\">\n      <label for=\"gestillt-dauer\">Duration: <span class=\"con_req\">*<\/span><\/label>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"gestillt-dauer\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"gestillt-dauer\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gestillt-dauer\" \/><\/span>\n    <\/div>\n    <\/div>\n  <\/div>\n\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 5: SUCKING HABITS ============ -->\n\n  <div class=\"form-section section-lutschgewohnheiten\">\n    <h3 class=\"section-title\">Sucking Habits<span class=\"con_req\">*<\/span><\/h3>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"lutschgewohnheiten\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"lutschgewohnheiten\" value=\"Pacifier\" \/><span class=\"wpcf7-list-item-label\">Pacifier<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"lutschgewohnheiten\" value=\"Thumb-sucking\" \/><span class=\"wpcf7-list-item-label\">Thumb-sucking<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"lutschgewohnheiten\" value=\"Feeding bottle for comfort\" \/><span class=\"wpcf7-list-item-label\">Feeding bottle for comfort<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"lutschgewohnheiten\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 6: GENERAL HEALTH (TABLE LAYOUT) ============ -->\n\n  <div class=\"form-section section-general-health\">\n    <h3 class=\"section-title\">General Health<\/h3>\n\n<div class=\"main_table_container\">\n  <table class=\"anamnese-table\">\n    <thead>\n      <tr>\n        <th colspan=\"2\" class=\"col-frage\">Medical Condition<\/th>\n      <\/tr>\n    <\/thead>\n\n    <tbody>\n      <tr>\n        <td>Asthma <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"asthma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"asthma\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Allergies <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"allergien\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergien\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergien\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Heart condition <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"herzfehler\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"herzfehler\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"herzfehler\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Diabetes <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"diabetes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>Epilepsy <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsie\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"epilepsie\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"epilepsie\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n      <tr>\n        <td>ADHD <span class=\"con_req\">*<\/span><\/td>\n        <td><span class=\"wpcf7-form-control-wrap\" data-name=\"adhs\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"adhs\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"adhs\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n      <\/tr>\n\n<tr>\n  <td>Does your child take any medication? <span class=\"con_req\">*<\/span><\/td>\n  <td><span class=\"wpcf7-form-control-wrap\" data-name=\"medikamente-kind\"><span class=\"wpcf7-form-control wpcf7-radio yn\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medikamente-kind\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medikamente-kind\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/td>\n<\/tr>\n<tr>\n  <td>If yes, please specify:<\/td>\n  <td><span class=\"wpcf7-form-control-wrap\" data-name=\"medikamente-kind-welche\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" id=\"medikamente-kind-welche\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medikamente-kind-welche\" \/><\/span><\/td>\n<\/tr>\n    <\/tbody>\n  <\/table>\n<\/div>\n\n  <\/div>\n  <!-- ============ SECTION 7: YOUR CHILD'S WORLD ============ -->\n\n  <div class=\"form-section section-kindeswelt\">\n    <h3 class=\"section-title\">Your Child&#8217;s World<\/h3>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"kuscheltier\">Favourite Soft Toy or Comfort Item: <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"kuscheltier\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"kuscheltier\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kuscheltier\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"was-mag-kind\">What Does Your Child Particularly Enjoy? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"was-mag-kind\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"was-mag-kind\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"was-mag-kind\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"sicherheit-kind\">What Helps Your Child Feel Safe and Comfortable? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"sicherheit-kind\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"sicherheit-kind\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"sicherheit-kind\" \/><\/span>\n  <\/div>\n<\/div>\n\n<div class=\"field-row\">\n  <div class=\"field-group full-width\">\n    <label for=\"wissenswertes-kind\">What Should We Know About Your Child? <span class=\"con_req\">*<\/span><\/label>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"wissenswertes-kind\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"wissenswertes-kind\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wissenswertes-kind\" \/><\/span>\n  <\/div>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 8: CONSENTS ============ -->\n\n  <div class=\"form-section section-consent\">\n\n<h3 class=\"section-title\">Consents and Administrative Information<span class=\"con_req\">*<\/span><\/h3>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"recall\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"recall[]\" value=\"I would like to receive reminders for preventive check-ups (recall service).\" \/><span class=\"wpcf7-list-item-label\">I would like to receive reminders for preventive check-ups (recall service).<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"terminbestaetigung\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"terminbestaetigung[]\" value=\"I agree to receive appointment confirmations by phone, SMS, or email.\" \/><span class=\"wpcf7-list-item-label\">I agree to receive appointment confirmations by phone, SMS, or email.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"datenschutz\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"datenschutz[]\" value=\"I have received the privacy information in accordance with Article 13 of the GDPR.\" \/><span class=\"wpcf7-list-item-label\">I have received the privacy information in accordance with Article 13 of the GDPR.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"vollstaendigkeit\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"vollstaendigkeit[]\" value=\"I confirm that the information I have provided is complete and accurate.\" \/><span class=\"wpcf7-list-item-label\">I confirm that the information I have provided is complete and accurate.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n  <\/div>\n\n  <!-- ============ SECTION 9: APPOINTMENT POLICY \/ MISSED APPOINTMENT FEE ============ -->\n\n  <div class=\"form-section section-policy\">\n\n\n<h3 class=\"section-title\">Appointment Policy \/ Missed Appointment Fee<\/h3>\n\n<p class=\"policy-text\">\n  Our practice operates on an appointment-only basis. If you are unable to attend an appointment, we kindly ask you to cancel at least 24 hours in advance. For appointments that are missed or cancelled at short notice, we reserve the right to charge a missed appointment fee in accordance with applicable legal requirements.\n  <span class=\"con_req\">*<\/span>\n<\/p>\n\n<div class=\"consent-row\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"ausfallhonorar-kenntnis\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"ausfallhonorar-kenntnis[]\" value=\"I acknowledge and have read this information.\" \/><span class=\"wpcf7-list-item-label\">I acknowledge and have read this information.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n\n  <\/div>\n\n  <div class=\"form-submit\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n  <\/div>\n\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_2\" name=\"_wpcf7_ak_js\" value=\"79\"\/><script>\ndocument.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Dear Parents,Since we hope to accompany your child for many years, we want to work together from the very beginning to spark your child&#8217;s curiosity and make dental visits as positive as possible. Children are truly bright: if a reward is promised for cooperating, they&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"content-type":"","footnotes":""},"class_list":["post-16973","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/pages\/16973","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/comments?post=16973"}],"version-history":[{"count":4,"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/pages\/16973\/revisions"}],"predecessor-version":[{"id":17206,"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/pages\/16973\/revisions\/17206"}],"wp:attachment":[{"href":"https:\/\/www.dr-worseck.de\/en\/wp-json\/wp\/v2\/media?parent=16973"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}