formlink - implant registration for doctors

IMPLANT REGISTRATION FOR DOCTORS

Implant registration is open for patients and doctors. If you as a doctor register the implant, keep your patient informed and document to pass on the data.

You will follow 4 chapters: 1. doctor identification, 2. patient identification 3. implant identification, 4. implantation data.

Only fields marked with * are required, but the more you provide, the better.
Fee 7.30€ + 7% VAT (as a service or charged in your bill)

1. DOCTOR IDENTIFICATION

doctor´s first name*

doctor´s last name*

medical degree(s), qualification(s)

clinic/practice of implantation*

street address city postal / ZIP code country

e-mail*

e-mail confirmation*

2. PATIENT IDENTIFICATION

use these fields with the consent of the patient

patient´s first name(s)*

patient´s last name*

patient degree(s)

country (patient)*

ZIP code (patient)

city (patient)

street, number and more (patient)

birthday*

day

month

year

patient agrees to be contacted by e-mail in this matter

yes

other contact

patient´s e-mail

e-mail confirmation

3. IMPLANT IDENTIFICATION

anatomical region*

The implant was exactly placed where ? (anatomy, which side etc.). Teeth: use the FDI numbering system or describe the region (e.g., left upper premolar). (max 300 letters)*

implant company*

implant name*

model number

serial number

you can upload QR codes or barcodes here (jpg, png)

I placed more implants

yes

the 2nd implant was exactly placed where ? (anatomy, which side etc.) (max 200 letters)

implant name of the 2nd implant

implant company of the 2nd implant

model number of the 2nd implant

serial number of the 2nd implant

Here you can add more implants in the same way as before (anatomy, implant name, implant model, model no., serial no.). Separate the entries with a semicolon (;).

You may enter here further information for finding the indication for placing the implant(s) (preconditions, medicaments ...).

4. IMPLANTATION DATA

date of implantation*

day

month

year

here you can describe any aspects in the implantation phase (max 300 letters)

supportive surgical measures

other

here you can describe more detailed supportive measures (e.g. procedure, used material, etc., max 300 letters)

here you can describe aspects in the post-surgery or use phase (max 300 letters)

here you can send a message or ask questions (max 300 letters)

Implantwiki/Implant-Register® assures that the data will not be passed on. They can be evaluated for anonymous, scientific, statistical purposes, where no connection to a person is possible. The data is stored securely, inaccessible via internet.
If any problem or suspicion arise with the implant, we will contact you by e-mail. Please inform us if there are any noteworthy developments with the implant you placed - good or bad.

Data can be queried on a patient-related basis if this is necessary for medical purposes (e. g. undesirable developments, change of doctor). You can use the contact form for any queries or add welcome@implant-register.com to your address book.

The registrant assures to be the named person who placed the implant, that the patient agreed to pass on the given data and that all information is correct. The registrant consents to the processing of his/her personal data as described above. The consent can be revoked at any time by e-mail, by her/him or the patient concerned..

fee (7.30€ + 7% VAT)*

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