Medical Questionnaire

Use our secure online form to complete your medical questionnaire. It's simple, easy and quick!

This questionnaire will allow the periodontist and his team to provide the best possible care and to reduce the risk of medical complication.

It's in the patient's interest to respond carefully and to advise of any change in their medical condition.

Person responsible for the protection of personal information: Julie Hayes 819-525-9255







    PERSONAL INFORMATION

    * = required fields



    Employer*

    MEDICAL HISTORY



    Specify

    Specify

    Specify

    Specify

    If yes, explain

    Specify

    If yes, cig./day and nb. years

    Frequency:

    Specify

    DENTAL HISTORY