Review of the confidential and secure health questionnaire

Ordre des dentistes du Québec

Dental records are compiled as part of the care that will be provided: they are protected by law and professional secrecy. They are kept in the office and only the dentist and his or her staff have access to them. The patient also has a right of access and rectification.

Patient information

Patient's date of birth

Medical history

Have you suffered or are you suffering from:

Blood problems

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

Other aspects

COVID-19 Informations

Health status of the patient and any accompanying person in the 14 days prior to the appointment:

Please note that an affirmative answer to any of these questions will require further questioning by your professional before confirming your dental appointment.

Check the corresponding boxes and specify the dates of appearance

Consent to communicate with a health professional

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

We would like to inform you that in the event of cancellation of your appointment, cancellation fees may apply in accordance with our current policy.

Patient or guardian signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.