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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