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Patient info

First visit form

Before your first appointment at the clinic, you will have to fill out a form that gives us all the relevant information concerning your health. To speed things up, we ask that you fill out the form at home or send it to us online.

If you must cancel your appointment, please inform us by telephone or e-mail at least 48 hours in advance. Otherwise, you will be charged a service fee.

To fill out the paper form:

–  TDownload the form (PDF format).
–  Fill out the form and print it.
–  Bring it with you for your first appointment.

To fill out the form online:

Confidential medical-dental questionnaire

The dental file will be used within the context of the care that is provided The information is protected by law and by professional secrecy. It will be kept at the office, and only the dentists and their staff will have access to it. The patient also has the right to access and correct the information.

Personal information

Name:
Gender: FM

Adresse:

Address:
City:
Province

Postal code:

Phone (home):
Phone (work):

Cell phone: Email Date of birth:

Health Insurance Card number:
Expirations (year/month):
If you are under 18 years of age, name of your parent/guardian:
ParentGuardian

Contact in case of emergency:

Name: Relationship with the patient:
Main telephone: Cell phone:

Medical history

Weight:
Height:
Are you currently under a doctor's care? OuiNon
If yes, for what reason?
Your doctor's name:
Your doctor’s phone number:
Hormones?
YesNo
Are you pregnant?
YesNo

Are you currently taking any medications or have you taken any medications within the last six months? YesNo
If yes, which ones?
Do you take natural or homeopathic products? YesNo
If yes, please specify:
Have you recently undergone a significant change in your body weight?
YesNo
Do you breastfeed? YesNo

Have you suffered from or are you currently suffering from any of the following:

Heart problems (infarction, angina, surgery, etc.) YesNo
Rheumatic fever YesNo
Heart infection (endocarditis) YesNo
Surgery to install or replace a valve YesNo
Blood problems (hemophilia, anemia, prolonged bleeding)
YesNo
Other blood problems?
Blood pressure: NormalLowHigh
Frequent colds or sinusitis YesNo
Digestive problems YesNo
Please specify the digestive problems:

Stomach problems
UlcerReflux
Liver problems (hepatitis A, B or C, cirrhosis)
YesNo
Frequent headaches
YesNo
Kidney problems
YesNo
Pain in the jaw joints?
YesNo
Dizziness, fainting spells
YesNo
Do you suffer from dry mouth?
yesNo
Earaches
YesNo
Hay fever
YesNo

Do you urinate frequently?
YesNo
Chronic pain
YesNo
Sexually transmitted infections (STI)
YesNo
Osteoporosis
YesNo
Diabetes
YesNo
Osteoporosis prevention or treatment (e.g.: pills)
YesNo
Thyroid problems
YesNo
Annual or monthly injection
YesNo
Skin diseases
YesNo
Do you take bisphosphonates?
YesNo
Eye problems
YesNo
Epilepsy
YesNo
Arthritis
YesNo
Neural disorders
YesNo
Psychiatric illnesses
YesNo
Please specify the illness:
Asthma
YesNo
Cancer (tumour)
YesNo
Have you ever undergone radiotherapy or chemotherapy treatments?
YesNo
Do you suffer from Acquired Immunodeficiency Syndrome (AIDS)?
YesNo
Are you seropositive?
YesNo
Do you have any artificial joints?
YesNo

Have you ever had an allergic reaction to any of the following products?

Latex
yesNo
Penicillin
YesNo
Other antibiotics
YesNo
Codeine
YesNo
Aspirin
YesNo
Sulfonamides
YesNo

Anesthetics
YesNo
Food
YesNo
Products containing iodine
YesNo
Other:

Other medical conditions that you would like to mention:

Other aspects

Do you snore?
YesNo
Do you suffer from sleep apnea?
YesNo
Do you drink alcohol?
YesNo
If yes, how frequently?

Do you consume drugs?
YesNo
Do you take methadone?
YesNo
Are you a smoker?
YesNo
Have you ever been hospitalized or undergone any type of surgery other than dental surgery?
YesNo
If yes, which type and when?
Comments

Dental information

Reason for your visit:
Last visit to the dentist:
0-6 months6-12 months+ de 12 months
Are you anxious about dental treatments?
YesNo
Treatments received:

Would you prefer to discuss your health condition with your dentist in private?
YesNo

Have you ever undergone any of the following dental treatments or services?

Demonstration of oral hygiene
YesNo
Gum treatment
YesNo
Orthodontic treatment (braces)
YesNo
Root canal treatment
YesNo
Fillings (repairs)
YesNo
Crown(s) or bridge(s)
YesNo

Full or partial dentures
YesNo
Oral surgery or extraction
YesNo
Dental implants
YesNo
Dental radiography
YesNo

Other


For professional use only:



Make an appointment

To make an appointment, you can call us at 450-437-6446 or fill out the following online form.
If this is your first visit, click here to open a medical file.
We will contact you soon by phone or by e-mail to confirm your appointment or to suggest a different time.

 

Making an appointment

Your availability:
Your preferences:

Confirmation of appointment by:
Comments, questions?

Personal information

First name:
Last name:
Phone:
Email:



Make your life easier with dental insurance

No need to worry: Clinique dentaire Boisbriand will take care of sending your dental insurance forms electronically. In most cases, the amount that is accepted for your dental treatments is sent almost immediately. All you have to pay when you visit the dentist is the deductible and the percentage that your insurer does not cover.

Insurance coverage varies depending on the agreement between the insurance company and your employer. We are not legally permitted to overcharge your insurance company or not collect the difference from you. Therefore, it is your responsibility to familiarize yourself with your coverage and the maximum amount that you can claim per year.

For patients whose insurance forms cannot be sent electronically, we will fill them out quickly and hand them back to you. You can then pay the fees at the clinic and send the duly completed forms to your insurer. Upon request from your insurer, we will be happy to provide a treatment plan or an estimate.

Dental services covered by the RAMQ

Our clinic is a member of the Québec health insurance plan administered by the Régie de l’assurance maladie du Québec (RAMQ), which covers certain services for children under the age of 10 years, along with recipients of last-resort financial assistance and their dependants. Consult this flyer to learn more!

Post-treatment survey

In our ongoing effort to improve the quality of our services, we invite our clients to respond to a short survey. The objective of this new approach is to measure your level of satisfaction and determine which aspects of our practice can be improved. Please note that the survey is anonymous.

1) Who treated you?
2) What is your level of satisfaction with respect to the care that you received?
3) What is your level of satisfaction with respect to the attitude of the personnel?
4) What is your level of satisfaction with respect to the quality of the instruments and technology used?
5) In a few lines, please describe the positive aspects that you noticed during your most recent visit.
6) Following your most recent visit to the dentist, please explain any aspects that can be improved.



Refer to a friend

Are you very satisfied with the care that you received at our clinic? Thank us by referring us to someone you know.

Your friend’s e-mail address
Your name