Medical form

Ordre des dentistes du Québec

Dental records are considered part of patient care. Dental records are protected by the law and professional secrecy, and they are stored at the dental clinic. Only the dentist and dental staff may access patient’s dental records. Patients have the right to access and correct their information.

Patient information


Birth date

Custodian fees


Dental history

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

I, the undersigned, declare that I have read, understood, inquired and answered the forensic questionnaire above to the best of my knowledge. I hereby agree to notify you of any change in my state of health. I authorize the constitution of my dental file, its follow-up as well as my inscription on the recall list of the dentist (s) treating (s). I have been informed that my dental record will be kept in the office at all times and that only the dentist (s) and his / her auxiliary staff will have access. I was also informed of my right to consult my file, to request a correction and to withdraw from the recall list.


For Dentist

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


Fields marked with an asterisk (*) are required.