Medical questionnaire |

Patient information

Men

Women

Last name of the patient*

First name of the patient*

Email of the patient*

Are you a beneficiary of a social assistance program in Quebec?

Yes

Address

Adress and apartment*

City*

Postal code*

Home phone

Cell phone

Office phone

Post

Birth date

Year*

Month*

Day*

Health insurance number

Expiry

If you are under 18, write the name of the parent

OR guardian

referred by

Custodian fees

Himself*

Yes

Name (of) responsible

First name (of) responsible

Address

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Dental history

Medical history

Consent to communicate with a health professional

List of my generalist doctor(s), specialist doctor(s), pharmacist, other

Name, function, establishment and telephone*

I, the undersigned, declare that I have read, understood, inquired and answered the forensic questionnaire above to the best of my knowledge. I hereby agree to notify you of any change in my state of health. I authorize the constitution of my dental file, its follow-up as well as my inscription on the recall list of the dentist (s) treating (s). I have been informed that my dental record will be kept in the office at all times and that only the dentist (s) and his / her auxiliary staff will have access. I was also informed of my right to consult my file, to request a correction and to withdraw from the recall list.

Signature:

For Dentist

I have read the answers to the registration questionnaire and taking the usual measures as appropriate.

Signature:

Medical questionnaire

Medical questionnaire

Patient information

Address

Birth date

Custodian fees

Address

Dental history

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

Have you ever had an allergic reaction or other to the following products:

Other aspects

Consent to communicate with a health professional

For Dentist

Medical questionnaire

Medical questionnaire

Patient information

Address

Birth date

Custodian fees

Address

Dental history

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

Have you ever had an allergic reaction or other to the following products:

Other aspects

Consent to communicate with a health professional

For Dentist

Search

Problems

Solutions

Videos

Cas traités