COVID questionnaire - Centre dentaire du Vieux Sherbrooke

Patient information

Last name of the patient*

First name of the patient*

Email of the patient*

Patient's date of birth

Year*

Month*

Day*

Medical history

Note or other medical conditions to mention

Is there any other information we haven't asked for that might be useful? If so, please explain:*

Yes

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

Do you have to be in isolation because of the COVID-19?*

Yes

Are you in the period between 5 and 10 days following your 5 day home isolation due to covid-19?*

Yes

Consent to communicate with a health professional

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

Name

Function

Establishment

Telephone

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

Delete signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.

Review of the confidential and secure health questionnaire

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:

Consent to communicate with a health professional