Confidential and Secure Health Questionnaire

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

Man

Women

Last name of the patient*

First name of the patient*

Email of the patient*

Are you a beneficiary of a social assistance program in Quebec?

Yes

No

Address

Adress and apartment*

City*

Postal code*

Home phone

Cell phone

Office phone

Post

In an emergency, call :

Name

Patient relationship

Main phone

Tel. cell.

Birth date

Year*

Month*

Day*

Health insurance number

Expiry

If you are under 18, write the name of the parent

OR guardian

referred by

Custodian fees

Himself*

Yes

No

Name (of) responsible

First name (of) responsible

Address

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Dental history

Reason for visit*

Do you fear dental treatment? Specify: *

A little

A lot

Not at all

Last visit:*

0 to 6 months

6 to 12 months

+ 12 months

What is the full name of the treating dentist: *

Treatment(s) received:

With panoramic dental radiography (large X-ray):*

Yes

No

With intraoral dental x-rays (small x-rays): *

Yes

No

Medical history

Would you like to speak privately with your dentist?*

Yes

No

Are you being treated by a physician?*

Yes

No

Have you ever had surgery or been hospitalized within the last 5 years? *

Yes

No

Do you have joint prostheses (hip, knee, etc.)?*

Yes

No

Have you gained or lost a lot of weight recently?*

Yes

No

Are you pregnant?*

Yes

No

Are you breastfeeding?*

Yes

No

Are you taking natural or homeopathic products?*

Yes

No

Are you taking medication?*

Yes

No

Are you taking birth control or hormones ?*

Yes

No

Reason, details and date

Reason, details and date*

Please check Yes or No for each current or past condition

Blood disorders (hemophilia, anemia, prolonged bleeding)*

Yes

No

Heart conditions - Infarction (heart attack), angina, surgery, etc.*

Yes

No

Heart conditions - Heart infection (endocarditis)*

Yes

No

Heart conditions - Surgery to replace or repair a valve /cusp*

Yes

No

Blood pressure (high - low)*

Yes

No

Dizziness, fainting*

Yes

No

Frequent headaches*

Yes

No

Jaw pain*

Yes

No

Liver disorders (hepatitis A, B, C. cirrhosis, etc.)*

Yes

No

Digestive system disorders or diseases*

Yes

No

Stomach disorders (ulcer - reflux)*

Yes

No

Kidney disorders*

Yes

No

Diabetes*

Yes

No

Thyroid disorders*

Yes

No

Cancer (tumour) - Radiotherapy / Chemotherapy*

Yes

No

Do you suffer from dry mouth?*

Yes

No

Sexually transmitted or blood-borne infections (STBBI)*

Yes

No

Skin diseases*

Yes

No

Feu sauvages*

Yes

No

Eye disorders*

Yes

No

Earaches*

Yes

No

Arthritis*

Yes

No

Osteoporosis - Prevention / treatment (e.g.: tablets)*

Yes

No

Osteoporosis - Annual or monthly injection*

Yes

No

Chronic pain*

Yes

No

Epilepsy*

Yes

No

Nervous system disorders or diseases*

Yes

No

Mental disorders or illnesses*

Yes

No

Frequent colds or sinusitis*

Yes

No

Tuberculosis or lung disorders*

Yes

No

Asthma*

Yes

No

Hay fever / seasonal allergies*

Yes

No

Allergy or manifestation with products containing:*

Yes

No

Other aspects

Do you snore?*

Yes

No

Do you suffer from sleep apnea? *

Yes

No

Do you smoke? cig./day ? or ex-smoker*

Yes

No

Do you drink alcohol? Frequency ?*

Yes

No

Do you take drugs?*

Yes

No

Do you take methadone?*

Yes

No

Consent to communicate with a health professional

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

Name*

Function*

Establishment*

Telephone*

POLICY OF THE CLINIC

Welcome to the Messier & Martin dental clinic!

Our team works hard to provide you with quality dental care and an exceptional experience. Consequently, daily management is essential to the functioning of our clinic. In order to ensure this quality, your contribution can add enormous value and will be greatly appreciated.

1. Please arrive 5 minutes before your appointment.


2. Leave your shoes at reception to avoid damaging the dental equipment. Disinfected shoes are available.


3. Please note that we offer the service of electronic transmission of claims. However, for each claim we ask you to pay upfront and the paiement will be sent to the subscriber.


4. It is your responsibility to verify your insurance coverage before scheduling an appointment. If necessary, our team can send a treatment plan in advance. (Be aware that the answer will be sent to the subscriber and not to the dentist.)


5. Accepted payment methods are: cash, debit, visa, mastercard and bank transfer.

Cancellation Policy

Due to high demand for appointments, we have implemented certain measures regarding cancellations and absences to provide optimal service to all our patients.

1. Mandatory Confirmation: You must confirm your attendance at least 24 hours before your appointment. Failure to confirm may result in your appointment being given to another patient.


2. Absences and Late Cancellations: After three missed appointments, including cancellations made less than 24 hours in advance or less than 7 days in advance for major treatments, we reserve the right to close your file.


3. New Patients: A patient who misses their first appointment will not be able to schedule another one.


4. File Reactivation: If your file is closed due to multiple absences or late cancellations, a reactivation fee of $50 will apply,

Last name :

Name :

I confirm that I have read and fully understand the policies mentioned above.

Patient signature :

Sign in the box below.

Delete signature

You must sign the questionnaire

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