Contact-us now:
(514) 648-7211
FOLLOW US :
Menu Item
Google+
YouTube
Twitter
Our services
General dentistry treatments
Dental Cleaning
Restoration of dental implants
Dental bridge
Root canal treatment
Pediatric dentistry
Dental Surgery
Gum graft procedure and gingival regeneration
Wisdom tooth extraction
Dental implants
Dental implants
Dental bone graft and bone regeneration
Orthodontics
Invisalign and clear braces
Fixed orthodontics
Cosmetic Dentistry
Porcelain veneers
Teeth whitening
Composite white fillings
Sleep apnea treatment and snoring solutions
Jaw pain treatment
Neuromuscular dentistry
About us
Our team
Photo Gallery
Virtual tour
Latest dental technologies
Dental emergency
Contact-us
Medical Form
English
Français
Our services
General dentistry treatments
Dental Cleaning
Restoration of dental implants
Dental bridge
Root canal treatment
Pediatric dentistry
Dental Surgery
Gum graft procedure and gingival regeneration
Wisdom tooth extraction
Dental implants
Dental implants
Dental bone graft and bone regeneration
Orthodontics
Invisalign and clear braces
Fixed orthodontics
Cosmetic Dentistry
Porcelain veneers
Teeth whitening
Composite white fillings
Sleep apnea treatment and snoring solutions
Jaw pain treatment
Neuromuscular dentistry
About us
Our team
Photo Gallery
Virtual tour
Latest dental technologies
Dental emergency
Contact-us
Medical Form
English
Français
Medical Form
1
2
3
Sex
Male
Female
Address
Firstname
*
City
*
Nom
*
Postal Code
Home phone
Work phone
Cellular
Birthdate
*
Email
*
RAMQ number
*
Expiration date
Social Insurance Number
If you are under 18 years enter parent name
Yes
As a matter of urgency, contact
Parent or tutor
Reason for visit
Addressed by
Are you on welfare program?
Yes
No
1. Are you under a physican's care now ?
If yes, reason :
Yes
No
Name of your doctor:
Phone
2. Are you taking any medication or have you taken durigng the last 6 months ?
If yes, which:
Yes
No
3. Do you take homeopathic or natural products ?
Yes
No
Do you take oral contraceptive ?
Yes
No
hormones ?
Yes
No
4. Have you gained or lost a lot of weight recently ?
Yes
No
5. Are you pregnant ?
Yes
No
you breastfeed ?
Yes
No
Have you suffered or do you suffer from :
6. Cardiac trouble
Yes
No
Infarct
Yes
No
Angina
Yes
No
Valvular trouble
Yes
No
Heart murmur
Yes
No
Congenital cardiac disease
Yes
No
Pain chest during effort
Yes
No
Comary insuffisant
Yes
No
7. Blood transfusion
Yes
No
8. Rheumatic fever
Yes
No
9. Blood problems :
Yes
No
Hemophilia
Yes
No
Bring blood
Yes
No
Anemia
Yes
No
Anormal bleeding or hemoragy during surgery
Yes
No
Other
Yes
No
10. Arterial tension (pressure)
Low
High
Yes
No
11. Frequent colds or sinusitis
Yes
No
12. Apoplexy
Yes
No
13. Pulmonary problems
Yes
No
Chronic bronchitis
Yes
No
Pneumonia
Yes
No
Emphysema
Yes
No
Tuberculosis
Yes
No
14. Sinusiis
Yes
No
15. Yellows
Yes
No
16. Hépatitis B
Yes
No
17. Hépatitis C
Yes
No
18. Digestive trouble
Yes
No
19. Peptic ulcer
Yes
No
20. Liver trouble (hepatitis A,B,C or cirrhosis)
Yes
No
21. Kidney trouble
Yes
No
22. Often you urinate ?
Yes
No
23. Sexually Transmitted Infections
Yes
No
24. Diabete
Yes
No
25. Thyroide trouble
Yes
No
26. Skin disease
Yes
No
27. Cerebrovascular accident
Yes
No
28. Ocular problems(eyes)
Yes
No
29. Arthritis
Yes
No
30. Osteoporosis
Yes
No
31. Epilepsy
Yes
No
32. Nerve trouble
Yes
No
33. Psychiatric diseases
Yes
No
34. Frequent head trouble
Yes
No
35. Dizziness, fainting
Yes
No
36. Ear trouble
Yes
No
37. Hay fever
Yes
No
38. Asthma
Yes
No
39. Do you smoke ?
Yes
No
How many cigarette?
40. Have you ever hard radiation therapy and / or chemotherapy (tumor) ?
Yes
No
41. Do you have AIDS?
Yes
No
42. Are you HIV positive ?
Yes
No
43. Do you have articular prothesis ?
Yes
No
44. Do you snore or have you been told that you snore?.
Yes
No
45. Have you ever had an allergic reaction or other products following :
Latex
Yes
No
Aliments
Yes
No
Iodine
Yes
No
Aspirin
Yes
No
Sulfamides
Yes
No
Penicillin
Yes
No
Codeine
Yes
No
Other antibiotic
Yes
No
Local anesthesia
Yes
No
Other
Yes
No
46. Do you consume drugs ?
Yes
No
47. Do you consume alcohol ?
Little or not
Moderate
Lot
Yes
No
48. Have you ever been hospitalized or had surgery other than dental ?
Yes
No
If so, what and when:
Date
Date
Date
49. Are you afraid of dental treatment ?
Little
Lot
Not at all
Yes
No
50. Would you like to discuss your health with your dentist in private?
Yes
No
51. Dental insurance Yes or No?
Yes
No
52. Insurance company
53. Subscriber name
54. Subscriber birthdate
55. Policy number
56. Identification number
57. How have your know about our clinic
Internet
Facebook
Porte à Porte
Virgin Radio 95.9 FM
Énergie 94.3 FM
TSN
Patient
Employé
Dentiste
En passant
Comment :
