Confidential and Secure Health Questionnaire

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

Last name of the patient*

First name of the patient*

Email of the patient*

Patient's date of birth

Year*

Month*

Day*

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

Patient or guardian signature

Delete signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.

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