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Confidential health questionnaire

We ask you to answer all questions to get acquainted with you and serve you better. Please sign in the designated place below before any dental treatment. The endodontist may refuse to treat a client who does not complete this questionnaire.

Medical history (past five years)

IMPORTANT

The cost of therapy will be discussed at the time of booking.

Our different means of payment are the following:
1- Cash, debit card
2- Credit card (Visa, MasterCard)
Patients with dental insurance are fully responsible for payment of fees. We will provide you with the necessary documentation to prepare your insurance claim.

Following your endodontic treatment, a permanent restoration (crown, filling, etc.) will be required. This restoration is not included in the cost of your treatment and must be completed by your dentist as soon as possible to minimize the risk of dental fractures.

I, the undersigned, hereby declare that I have read and understood the above information and have completed the medical-dental questionnaire to the best of my knowledge. to the best of my knowledge.

Patient or guardian signature

Delete signature

You must sign the questionnaire

Date*

Fields marked with an asterisk (*) are required.

Next step

Confidential health questionnaire

Patient information

Responsible for payment (if under 18)

Family physician (if applicable)

Medical history (past five years)

Are you suffering or have you ever suffered from:

Dental history (please indicate if you have previously undergone the following)

IMPORTANT

Confidential health questionnaire

Patient information

Responsible for payment (if under 18)

Family physician (if applicable)

Medical history (past five years)

Are you suffering or have you ever suffered from:

Dental history (please indicate if you have previously undergone the following)

Consent form for the collection and use of personal information

IMPORTANT