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Kieferortho Rotkreuz
Buonaserstrasse 12
6343 Rotkreuz

T +41 41 252 10 10

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Assignment form

Use the following form or send an e-mail directly to

Patient details

Last name

First name

For children and adolescents: Surname and first name of the parent

Date of birth

Address

PLZ / Ort

Phone

Email

Referring practice

Praxis

Email practice

Last name dentist / doctor

First name dentist / doctor

Reason for referral / diagnosis

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Available documents Dental X-ray, OPT, FR, DVT, models, etc.

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Kieferortho Rotkreuz
Buonaserstrasse 12
6343 Rotkreuz

T +41 41 252 10 10

kieferortho-rotkreuz.ch

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Kieferortho Rotkreuz
Buonaserstrasse 12
6343 Rotkreuz

T +41 41 252 10 10

Google Maps

Tuesday to Friday
08.00 to 12.30
13.30 to 17.00

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Tax point value
CHF 1.10

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