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

Address

Birth date

Costs and fees manager

Address

Dental informations

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 ather to the following products:

Other aspects


Consent to communicate with a health professional

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


Do you have a doctor's preference?


Patient or guardian signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.