CONFIDENTIAL REGISTRATION FORM



PATIENT INFORMATION










ADDRESS















PERSON RESPONSIBLE FOR PAYMENT











ADDRESS
















OTHER INFORMATION

















DENTAL PLAN















MEDICAL HISTORY



GENERAL INFORMATION




kg


cm












































HAVE YOU SUFFERED OR ARE YOU SUFFERING FROM:





Case 1





Case 2





Case 3





Case 4





Case 5







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:






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.





I agree to receive emails about my treatment plan, insurance papers, appointments or any other relevant information related to my dental records.


RESERVED FOR THE DENTIST

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