Complete medical questionnaire - Centre Dentaire Côte-Vertu

Patient information

Man

Women

Other

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

Costs and fees manager

Himself*

Yes

Name (of) responsible

First name (of) responsible

Address

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Dental informations

Medical history

Sleep and breathing

COVID-19 Informations

N. B. The Ordre des dentistes du Québec strictly prohibits the use of cell phones in dental clinics. Thank you for your understanding and collaboration on this matter.

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

Patient or guardian signature

Delete signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.

Confidential and Secure Health Questionnaire

Confidential and Secure Health Questionnaire

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

Sleep and breathing

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