Unfortunately some of the lines in this standard form is in danish. Here is a little information and translation:

CPR.Nr.: Your danish personal number .You find it on your yellow card .
Lægevalg: Choose doctor : You simply choose dr Flindt-Hansen
Konsultation : Consultation : Choose konsultation
Specifikation til konsultation : Choose Alm. konsultation
Dato for konsultation : Date of consultation. Choose your preferred date .
Tidspunkt : Time : Choose your preferred time interval. 11.00 means and 13.00 means 1pm.
Din kommentar til lægen: Your comment to us. You do not need to fill out
Bekræft E-mail adresse : confirm email adress
Send tidsbestilling : Send

Please avoid errors when you write your CPR number