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Confidential Medical-Dental Questionnaire
A patient's dental file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office, where only the dentist and his/her staff have access to it. Patients are also entitled to access their file and make corrections.
Consent to communicate with a health professional
Dr. Ali Elsayegh
General Dentist at Elsayegh Dental Clinic
+1 (514) 866-6556
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* Indicates required question
Title:
*
Mr.
Ms.
Other:
First Name:
*
Your answer
Last Name:
*
Your answer
I am filling this questionnaire as:
*
The patient him/herself
The parent or guardian of the patient (if under 14 years old)
The legal representative of the patient
Other:
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