Appointment: Cosmetic Dental Pierre Deslauriers

*Indicate the desired time and date*

Date:	( day-month-year )

Hour:	( 24h format. ex: 16h )

Confirm appointment by:	Telephone E-mail

Comments :


*IPersonal Information*

Fist Name:

Last Name:

Gender :	Male Female

Address:

City:

Postal Code :


Home Telephone Number:

Business Telephone Number:	poste :

Cellular:

E-mail:

Weight: :

Height: :

Date of Birth:	Day Month Year

Marital Status:

Employer :

Employer Address:

Medical Insurance Number:

Expiration Date:	Year Month

Social Insurance Number:

Financial guardian, or, in case of a child, Name of the parent:

Referred by:


*Information on the employee taking part in the insurance program*

Name of the insurance company:

Plan number:

Number of the section or division:

Certificate and identity number:

Name of the insured person:

Are you covered by another insurance plan?

If yes, name of the company:

Plan number:

Number of the section or division:

Certificate and identity number:


*Help us get to know you better*

Are you satisfied with the appearance of your teeth?

Are you considerably worried of the financial means required to achieve an excellent oral health?

Each time you visit a dentist, are you constantly frustrated because you have to receive new treatments?

Do you have the feeling that one day, you will have to wear prostheses?

Do you have fears?

Medical history


Are you currently under the care of a doctor?

If yes, Name

Surname :

Telephone:	Extension:

Are you currently taking medications or have taken some medication during the last six months?

If yes, which ones?

Are you pregnant?

Are you taking oral contraceptives? (Birth control pill)


*Have you ever suffered from?*

Cardiac problems (infarctus, angina, valves or respiratory)

Rheumatic fever

Prolonged bleeding

Anaemia

Arterial tension	High Low

Frequent colds or sinus infections

Tuberculosis or pulmonary problems

Digestive problems

Stomach ulcers

Liver problems (Hepatitis virus A, B, C, cirrhosis)

Kidney problems

Venereal Diseases (MTS)

Diabetes

Thyroid problems

Skin diseases

Ocular problems (eyes)

Arthritis

Epilepsy

Nervous system problems

Frequent headaches

Giddiness or fainting

Ear problems

Hay fever

Asthma

Smoker

Have you ever received radiotherapy or chemotherapy?

Do you suffer from acquired immune deficiency syndrome (AIDS)

Have you tested positive for AIDS?

Do you have any joint prostheses?


*Have you ever had a reaction to the following products?*

Food

Penicillin

Aspirin

Iodine

Sulphonamide

Codeine

Local anaesthesia

Others

Have you ever been hospitalize or had any form of surgery other than oral surgery?
If yes, which ones? When?	Year Description Year Description Year Description

Would you like to privately discuss your health with your dentist?	Observations

Dental history


Last visit:	0-6 months 6-12 months + than 12 months Treatments received

*Have you ever received any of the following treatments?*

Oral hygiene demonstration

Gum treatment

Orthodontic treatment (Braces)

Root canal

Fillings (repairs)

Crowns and/or bridges

Complete or partial prostheses

Oral surgery or extractions

Dental implants

Dental radiographies

Others

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