COVID-19 Update

Dear families,

We would like to thank you for your patience and your effort to flatten the curve for the safety of everyone.

In order to sustain this collective effort, we have added new protective equipment and established a new protocol for your dental appointment.

Please review the following recommendations prior to your next visit with us:

Fill out the online COVID-19 screening form for each person entering the dental clinic.
There is a limit of 1 parent/guardian per patient.
It is highly recommended to wear an artisanal or surgical facial mask.
Wait for our secretary to call you before entering the clinic.
Once in the clinic, our dental assistant will review the COVID-19 screening questions with you. You will then be asked to wash your hands and to put on a protective blouse if necessary.
Usage of the washroom will be restricted. Please keep that in mind prior to leaving your home.
It is recommended not to use your cell phone in the clinic.

Thank you for your support and your understanding. May we all go through this pandemic together in safety and in health.

The C.D.P.P.M. team

Covid-19

Centre dentaire Pédiatrique & prosthodontique de Montréal

Personal Information (fields marked with an asterisk are mandatory)

Last name:*

First name:*

Gender:*
FM

Age:

Address:

City:

Postal code:

Home phone:*

Work phone:
Extention:

E-mail:*

Weight:

Height:

Birth date:
Année:

Medicare Card No:

Expiry
Year :

If child, parent's name:

In case of emergency call:

Reason for visiting us:

Medical History

Are you currently under the care of a physician?

If yes, provide his/her name:

Physician's phone:

Are you currently taking or have you taken any medication in the last six months

If yes, please describe them below:

Have you had a marked loss or gain of weight lately?

Are you pregnant?

Are you taking a hormonal contraceptive?

Do you or have you ever had any of the following:

Heart disease (infarction, angina, valve problems, shortness of breath)?

Rheumatic fever?

Prolonged bleeding?

Anemia?

Blood pressure?

Frequent colds or sinusitis?

Tuberculosis or lung problems?

Digestive problems?

Stomach ulcers?

Livers problems (hepatitis A, B, C or cirrhosis)?

Kidney problems?

Sexually transmitted infections (STIs)?

Diabetes?

Thyroid problems?

Skin disease?

Vision problems?

Arthritis?

Epilepsy?

Nerve problems?

Frequent headaches?

Dizziness, fainting?

Earaches?

Hay fever?

Asthma?

Do you smoke?

Have you ever had radiation treatments or chemotherapy?

Do you have acquired immunodeficiency syndrome (AIDS)?

Have you tested positive for AIDS?

Do you have any joint prostheses?

Have you ever had an allergic reaction to any of the following:

Foods?

Penicillin?

Aspirin?

Iodine?

Sulpha drugs?

Codeine?

Local anesthetic?

Others?

Explain:

Have you ever been hospitalized or undergone surgery, other than dental surgery?

If yes, specify the type of surgery and when?

Do you wish to discuss your health with the dentist?

Comments

Dental History

Date of last dental visit:
0-6 months6-12 months+ 12 months

Traitements received

Have you had any of the following dental treatments or services?

Oral hygiene demonstration?

Gum treatment?

Orthodontic treatment (braces)?

Root canal treatment?

Fillings?

Crown(s) or bridges(s)?

Full or partial prostheses?

Dental implants?

Dental x-rays?

Others?

Thank you for taking the time to fill this form. We are looking forward meeting you on your next meeting.

Centre Dentaire Pédiatrique et Prosthodontique de Montréal (en)

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COVID-19 Update

Centre dentaire Pédiatrique & prosthodontique de Montréal