Medical questionnaire Endodontie Montérégie Saint Hubert

Personal information

First name*

Name*

Gender*

Non-Binary

Birth date*

Address*

City*

Province*

Postal code*

Contact details

Home phone

Office phone

Tel. cell.

Email*

In an emergency, call :

Name

Patient relationship " value="" />

Main phone

Tel. cell.

Dental informations

Reason for today's visit*

Do you fear dental treatment?*

Not at all

A little

A lot

Specify

Medical history

Consent to communicate with a health professional

General dentist, specialist dentist, family doctor, specialist doctor, pharmacist, etc.

Name

Function

Establishment/telephone

I consent to the dentist and his staff collecting relevant information compatible with the purpose of the file from or communicating such information to the health professionals listed above.<

Patient or guardian signature

Delete signature

You must sign the questionnaire

Date*

Confidential dental questionnaire

Confidential dental questionnaire

Personal information

Contact details

Dental informations

Medical history

Please check Yes or No for each current or past condition

Blood problems

Cardiac conditions

Other aspects

Allergie ou manifestation à ces produits :

Consent to communicate with a health professional