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 InformationDental HistoryMedical 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.

Confidential Information

General Information

Date of birth
First name
Last name
Email address
Postal Code
Cell Phone
Home Phone
Work phone
Ok to call at work?
To contact you

Other Information

Martial status
Underage 18


Full name
Work phone
Home phone

Our survey

Who can we thank for referring you?

Dental History

Personal Information

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

Please answer the following

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


If you are wearing a partial or complete artificial denture, please complete the following :
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
When did you receive your first partial or complete denture?
How long have you worn your present denture?

Medical History


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


Yes No     Yes No
1. hospitalization for illness or injury   26. arthritis
2. allergic reaction to   27. glaucoma
  aspirin, ibuprofen, acetaminophen
local anaesthetic
metals (gold, stainless steel)
any other medications
      28. contact lenses
      29. head or neck injuries
      30. epilepsy, convulsions (seizures)
      31. viral infections and cold sores
      32. any lumps or swelling in the mouth
      33. hives, skin rash, hay fever
      34. venereal disease
      35. hepatitis
      36. HIV / AIDS
      37. tumor, abnormal growth
3. heart problem   38. radiation therapy
4. heart murmur   39. chemotherapy
5. rheumatic fever   40. emotional problems
6. scarlet fever   41. psychiatric treatment
7. high blood pressure   42. antidepressant medication
8. low blood pressure   43. alcohol/drug dependency
9. a stroke   Are you
10. artificial prosthesis (heart valve or joints)   44. presently being treated for any illness
11. anemia or other blood disorder   45. aware of a change in your general health
12. prolonged bleeding due to a slight cut   46. often exhausted or fatigued
13. emphysema   47. subject to frequent headaches
14. tuberculosis   48. a heavy smoker (1 pack or more a day
15. asthma   49. considered a touchy person
16. sinus problems   50. often unhappy or depressed
17. kidney disease   51. easily upset or irritated
18. liver disease   52. FEMALE - taking birth control pills
19. jaundice   53. FEMALE – pregnant
20. thyroid or parathyroid disease   54. MALE - Prostate disorders
21. hormone deficiency        
22. high cholesterol        
23. diabetes        
24. stomach or duodenal ulcer        
25. digestive disorders        

Please describe any current medical treatment, impending surgery, or other medical treatment

List any medications, herbal supplements, and or vitamins taken within the last two years (Please bring list if have been prescribed by your doctor.)