Confidential Medical-dental Questionnaire


A patien's dental file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office. Where only the dentist and his or her staff have access to it. Patients are also entitled to access their file and make corrections.

Personal Information

For emergenciesm call :

Dental Information

Medical history

Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months

Please check Yes or No for each current or past condition

Heart conditions

Allergy or manifestation with products containing

Other aspects

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