Confidential and Secure Health Questionnaire

Ordre des dentistes du Québec

Dental records are compiled as part of the care that will be provided: they are protected by law and professional secrecy. They are kept in the office and only the dentist and his or her staff have access to them. The patient also has a right of access and rectification.

Patient information


Birth date

Custodian fees


Dental history

Medical history

Reason, details and date

Please check Yes or No for each current or past condition

Other aspects

Consent to communicate with a health professional

List of my generalist doctor(s), specialist doctor(s), pharmacist, other

Sign in the box below.

You must sign the questionnaire