Fill Out the Confidential Medical-Dental Form

Confidential Medical-Dental Form

A dental file is constituted as part of the ongoing care to be provided: it is protected by law and professional confidentiality. It is kept in the office and only the dentist and his or her staff have access to it. The patient also has a right of access and rectification. This form will allow the dentist and his or her staff to provide the best possible care and reduce the risk of medical complications. It is in the patient's interest to respond carefully and advise the dentist of any change in his or her health.

If you have questions about this form, don’t hesitate to contact our team at Clinique Dentaire Champlain in Brossard.

Personal Information

F
M

Contact Information

Dental Information

None
Some
A lot
0 – 6 months
6 – 12 months
Over 12 months
Yes
No
Yes
No

Medical Background

Yes
No
Yes
no
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Please Check Yes or No for Each of the Conditions, Whether Current or Past

Yes
No
Infarction, angina, surgery, etc.
Heart inflammation (endocarditis)
Valve or bypass surgery
High pressure
Low pressure
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Ulcer
Acid reflux
Yes
No
Yes
No
Yes
No
Yes
No
Radiotherapy
Chemotherapy
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Prevention / treatment (e.g. tablets)
Annual or monthly injection
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Latex
Sulfamides
Penicillin
Anesthetics
Other antibiotics
Food
Codeine
Products containing iodine
Aspirin

Other Factors

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Information

2151 Lapinière Boulevard, office B02, portal 1,

Brossard, QC 

J4W 2T5

Phone: 450‑923‑1361

Email: clchamplain@videotron.ca

Hours

Monday 8 :00 AM to 6 :00 PM
Tuesday to Thursday 8 :00 AM to 9 :00 PM
Friday 8 :00 AM to 8 :00 PM
Saturday and Sunday 9 :00 AM to 12 :00 PM

Emergency service 7 days a week
(appointment on the same day)

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