Confidential and Secure Health Questionnaire

Ordre des dentistes du Québec

Dental records are compiled as part of the care that will be provided: they are protected by law and professional secrecy. They are kept in the office and only the dentist and his or her staff have access to them. The patient also has a right of access and rectification.


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

Patient information


Birth date

Costs and fees manager


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

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

Patient or guardian signature

You must sign the questionnaire

Fields marked with an asterisk (*) are required.