Confidential Medical-dental Questionnaire

A patien's dental file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office. Where only the dentist and his or her staff have access to it. Patients are also entitled to access their file and make corrections.

Personal Information

Contact Information


For emergenciesm call :

Dental Information





Medical history












Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months

Please check Yes or No for each current or past condition


Heart conditions




































Allergy or manifestation with products containing










Other aspects









Please check the captcha