Becoming a Patient

Patient Registration Form

We would love to welcome you to the Alpstein Clinic. The first step in becoming a patient is to fill out the form below. Once received, one of our Patient Coordinators will be in touch with you to answer questions and provide detailed information about scheduling and the preparation of your personalized treatment plan and program.


Personal information

Title *
Name *
First name *
Date of Birth *

Contact information

Address *
Additional address
Zip code *
City *
Primary phone number *
Secondary phone number
E-Mail *
I allow you to send me patient-related data to this e-mail address.

More Information

Martial status
I am using a wheelchair

Emergency Contact

Personal information

Title *
Name *
First name *

Contact information

Telefonnummer *

Medical History


Main health compliant
Other illnesses
Family medical history
Additional exposures

Allergies and Habits


Dental status

I have gum problems
I have theeth with root canal
I have theeth with Amalgam filling
I have theeth with synthetic filling
I have Titanium implants
I have Zirconium dioxide implants
I have a craniomandibular dysfunction
I have a dental panoramic x-ray

Other treating doctor

Name of the clinic, hospital or practice
Name of the doctor
Zip code


basic health insurance

I have a basic insurance provider.
Name of basic health insurances provider *
Insurance number *
Zip code *
City *

supplementary health insurance

I have a supplementary insurance provider.
Name of supplementary health insurance provider *
Insurance number *
Zip code *
City *

send questionnaire

How did you find us?

How did you find us?

Terms of Services

I have read and understood the general terms and conditions (Terms of Service) and the Privacy Policy (Privacy Policy) *

I would like to register for the newsletter



American Medical Health Alliance

The Alpstein Clinic does not accept health insurance. If your health insurance coverage includes out-of-network and international care, you may want to see if you can receive reimbursement from your insurance company for some of your medical expenses at the clinic. The American Medical Health Alliance (AMHA) may be able to assist you. We are not affiliated with AMHA, but have found that some patients are able to get some expenses reimbursed by working with them. AHMA offers free consultations.

American Medical Health Alliance LLC. (AMHA) specializes in helping patients who pay-out-pocket for "Alternative/Holistic" medical care obtain reimbursements on FDA approved aspects of their care from their insurance payers. AMHA has been assisting Americans who elect to receive this care both domestically and internationally for over twenty-years. AMHA works on a contingency fee of 20% based on any successful insurance reimbursement. If AMHA does not successful obtain an insurance reimbursement, then nothing is paid to AMHA.

Filing claims for out-of-network providers is a slippery slope and restoring a patient’s out-of-pocket medical costs can prove difficult without the right tools. The process requires time, knowledge of claims processing, thorough communication skills, and record keeping. Many patients struggle with their insurers simply because they do not understand all the elements involved. Therefore, having a dedicated Insurance Reimbursement Advocate who understands the complex issues associated with insurance reimbursement is essential for success. Contact AMHA for a FREE insurance evaluation at 1-800-221-0817 or visit our website

Download here the AMHA Welcome Packet.


Do you have Questions?

First name *
Name *
Phone Number *
E-Mail *
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