Medical questionnaire

Consent

In accordance with the laws aimed at the protection of personal information, the following consents are given by the patient or by the person who has parental authority for the minor patient and who has accepted responsibility for the fees :

I consent to Dr Chamberland retaining in its records all relevant information relating to the treatment provided as well as the personal information necessary to fulfill the financial agreement;
I agree that Dr Chamberland may collect from any person and hold all information deemed necessary for the collection of the sums provided for in the financial agreement and that, for this purpose, it may transmit the said information to the appropriate party;
I agree that any person may provide the Dr Chamberland with said information;
I consent to the use of diagnostic and treatment data (photos, x-rays) for educational purposes, teaching, examinations, research, conferences and scientific publications.

Patient or guardian signature

Delete signature

Patient information

Man

Women

Other

Last name of the patient*

First name of the patient*

Email of the patient*

Are you a beneficiary of a social assistance program in Quebec?

Yes

No

Address

Adress and apartment*

City*

Postal code*

Home phone

Cell phone

Office phone

Post

Birth date

Year*

Month*

Day*

Health insurance number

Expiry

If you are under 18, write the name of the parent

OR guardian

referred by

Costs and fees manager

Himself*

Yes

No

Name (of) responsible

First name (of) responsible

Address

Adress and appartment

City

Postal code

Home phone

Cell phone

Office phone

Post

Dental informations

Medical history

Orthodontic history

Consent to communicate with a health professional

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

Name

Function

Establishment

Telephone

Patient or guardian signature

Delete signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.

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Confidential and Secure Health Questionnaire

Consent

Patient information

Address

Birth date

Costs and fees manager

Address

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:

Other aspects

Orthodontic history

Consent to communicate with a health professional

Confidential and Secure Health Questionnaire

Consent

Call us at

Dr. Sylvain Chamberland, Orthodontist

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