Medical form

Ordre des dentistes du Québec

Patient information

Address

Date of birth

Responsible Party

Address

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

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*





I hereby declare to have read, understood and have answered the survey dentalmed above to the best of my knowledge. 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.

Signature:

For Dentist

I have read the answers to the questionnaire.

Signature:

Fields marked with an asterisk (*) are required.