Medical Questionnaire

MEDICAL AND DENTAL QUESTIONNAIRE

A dental file is created as part of the care provided: it is protected by law and patient-physician privilege. It is kept in the office and only the orthodontist and their personnel have access to it. The patient also has the right to access and make corrections to the file.

Patient information*

Patient first name Patient last name

Sex*

M
F

Referred by*

Address*

Apt Town Province Postal Code

Home phone*

Mobile phone

Office phone

Ext.

Email

Do you have dental insurance*

Yes
No

Appointment confirmations made by*

Home
Office
Mobile
Email

Date of birth*

Health insurance number

Occupation*

Emergency contact*

Phone

Ext.

Under the age of 14, enter the name of the parent/guardian

Indicate

Parent
Guardian

Reasons for the consultation

Lack of space
Aesthetics of the smile
Impacted teeth
Functional orthodontics
Rehabilitation
Invisalign treatment
Malocclusion
Pain
Other

Please specify

PERSON RESPONSIBLE FOR FEES

Patient
Other individual

Responsible name

Contact information of person responsible for fees

Same as the patient

Address

Apt Town Province Postal code

Home phone

Mobile phone

Office phone

Ext.

Email

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MEDICAL AND DENTAL QUESTIONNAIRE