Confidential and Secure Health Questionnaire

Ordre des dentistes du Québec

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


Birth date

Dental informations

Have you ever had dental treatments such as

Information on growth (for children 10-14 years)

Girls only*

Medical history

Have you suffered or are you suffering from:

Blood problems

Have you ever had an allergic reaction or ather to the following products:

Autres aspects

COVID-19 Informations

Health status of the patient and any accompanying person in the 14 days prior to the appointment:

Please note that an affirmative answer to any of these questions will require further questioning by your professional before confirming your dental appointment.

I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
Fever, Shortness of breath, Dry cough, or Sore throat.

I confirm, to my knowledge:

Although there are no guarantees regarding the possibility of contracting COVID-19, my dentist and her staff will be following safety protocols as to best protect myself and the staff during treatment.

Consent to communicate with a health professional

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

Patient or guardian signature:

You must sign the questionnaire

Fields marked with an asterisk (*) are required.