CONFIDENTIAL REGISTRATION FORM

PATIENT INFORMATION

Last name

First name

Patient email

ADDRESS

Address and apartment number

City

Postal code

Home phone number

Cellphone number

Work number

Extension number

PERSON RESPONSIBLE FOR PAYMENT

Patient himself Yes No

Last name of person responsible

First name of person responsible

ADDRESS

Address and apartment number

City

Postal code

Home phone number

Cellphone number

Work number

Extension number

OTHER INFORMATION

Date of birth

Health insurance number

Expiry date

If you are under 18 years of age, please write the name of your parent

OR guardian

Referred by

Reason for your visit

DENTAL PLAN

Name of Policyholder

Insurance company

Plan or Policy number

Policyholder's Date of Birth

Certificate or ID number

MEDICAL HISTORY

DENTAL HISTORY

I, the undersigned, declare that I have read, understood, and answered the above medical-dental questionnaire to the best of my knowledge. I hereby undertake to notify you of any change in my health status. I authorize the creation of my dental file, its follow-up, and my registration on the callback list of the treating dentist(s). I have been informed that my dental record will be kept in the office at all times and that only the dentist(s) and their auxiliary staff will have access to it. I was also informed of my right to access my file, request a change and/or be removed from the callback list.

Signature:

I agree to receive emails about my treatment plan, insurance papers, appointments or any other relevant information related to my dental records. Yes No

RESERVED FOR THE DENTIST

I acknowledge that I have read the answers to the registration questionnaire and have taken the appropriate measures where necessary.

Signature:

CONFIDENTIAL REGISTRATION FORM

PATIENT INFORMATION

ADDRESS

PERSON RESPONSIBLE FOR PAYMENT

ADDRESS

OTHER INFORMATION

DENTAL PLAN

MEDICAL HISTORY

GENERAL INFORMATION

HAVE YOU SUFFERED OR ARE YOU SUFFERING FROM:

HAVE YOU HAD OR ARE YOU SUFFERING FROM ANY OF THE FOLLOWING BLOOD DISORDERS:

HAVE YOU EVER HAD AN ALLERGIC REACTION OR ANY TYPE OF REACTION TO ANY OF THE FOLLOWING:

DENTAL HISTORY

HAVE YOU EVER HAD DENTAL TREATMENTS SUCH AS:

RESERVED FOR THE DENTIST