New Patient Forms

Welcome to the Clinique Dentaire Ile Perrot secure “New Patient Forms" section. For new patients, this is an excellent online resource that allows you, from the comfort of your home or work, to complete all the necessary forms before your appointment. When you arrive at the clinic for your scheduled appointment, we will have you sign and date them. This allows us to serve you faster and more efficiently.

In this step-by-step process you will be asked to fill out 3 forms: Confidential Information • Dental History • Medical History

Once each form is filled, please press the Submit Button at the bottom of the page, your information will be automatically sent to us, thank you.

General Information
Gender
Date of birth
First name
Last name
Email address
Address
City
Postal Code
Cell Phone
Home Phone
Work phone
Ok to call at work?
To contact you	Cell Phone Home Phone Work Phone Email Text Messaging

CONTACT IN CASE OF AN EMERGENCY
Full name
Relationship
Work phone
Home phone

Personal Information
Most recent dental exam
How often do you have your teeth cleaned?
What is yout immediate dental concern?

Please answer the following
	Yes	No
1. unhappy with the appearance of your teeth
2. unfavorable dental experiences
3. dental fears
4. problems with effectiveness or bad reactions to dental anesthetic
5. orthodontic treatment (braces)
6. periodontal (gum) treatment
7. bleeding gums
8. avoid brushing any part of your mouth
9. part of your mouth is sensitive to temperature
10. sore teeth
11. a burning sensation in your mouth
12. difficulty swallowing
13. an unpleasant taste or odor in your mouth
14. dry mouth, throat, and or eyes
15. jaw problems (temporomandibular joint)
16. difficultly opening your mouth widely
17. stiff neck muscles
18. awaken with an awareness of your teeth or jaws
19. tension headaches
20. clench or grind your teeth
21. jaw clicking or popping
22. lost any teeth
23. do you sweat or tremble a lot during examination
24. do strange people or places make you afraid

SUPPLEMENTAL DENTURE HISTORY
If you are wearing a partial or complete artificial denture, please complete the following :
Yes	No
		Has your present denture been relined? When
		Is your present denture a problem? Describe
		Satisfied with the appearance?
		Satisfied with the comfort?
		Satisfied with the chewing ability?
Please list all surgeries, medical history or medications you are taking

New Patient Forms

Confidential Information

General Information

Other Information

CONTACT IN CASE OF AN EMERGENCY

Our survey

Dental History

Personal Information

Please answer the following

SUPPLEMENTAL DENTURE HISTORY

Medical History

OTHER INFORMATION

HAVE YOU EVER HAD THE FOLLOWING

When did you receive your first partial or complete denture?
How long have you worn your present denture?

OTHER INFORMATION
Name of physician
Reason for your last medical visit
What is your estimate of your general health?

Other Information
Martial status
Underage 18

Our survey
Who can we thank for referring you?