Medical form

Patient information

Last name of the patient

First name of the patient

Email the patient

Adress

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 Reason for visit

Custodian fees

Himself

Yes

Name (of) responsible

First name of the patient

Adress

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Medical history

Dental history

Information on growth (for children 10-14 years)

Is your child in active growth period?

Yes

Does your child seem to have reached puberty?

Yes

Girls only

Have menstruation started? If so, how long?

Yes

I hereby declare to have read, understood, myself informed and have answered the survey dentalmed above to the best of my kwledge. I hereby undertake to advise you of any change in my health. I authorize the constitution of my dental records, monitoring as well as my entry on the recall list (of) dentist (s) contractor (s). I was informed that my dental records will be kept at the office at all times and that (the) dentist (s) and its (their) support staff will (have) one (s) access. I was also informed of my right to see my file, to request a correction and will retire from the recall list.

Signature:

For Dentist

I have read the answers to the registration questionnaire and taking the usual measures as appropriate.

Signature:

Confidential Registration Questionnaire

Patient information

Adress

Birth date

Custodian fees

Adress

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:

Dental history

Avez-vous déjà eu des traitements dentaires tels que

Information on growth (for children 10-14 years)

Girls only

For Dentist