Appointment for the Toro Dental Clinics

If you do not have a file in one of our dental clinics and want to make an Appointment for the Toro Dental Clinics JEAN-TALON or NOTRE-DAME, please, fill the form below to provide us with some information to help us to open your file and save you time during your visit. If you already have a file with us, please complete only the top on making appointments. Please note that fields marked with “*” are required. Any cancellation of an appointment must be submitted no later than 48 hours prior to such appointment (thank you for your understanding). Your appointment time will be confirmed by our staff. If not available you will be offered options. Thank you for choosing Les Cliniques Toro.

Appointment for the Toro Dental Clinics ( sending confidential )

Your Name*

Your Adress*

Home phone*

If your cell number is your primary phone, please, enter it here

Work or Cell Phone (with extension)

Phone confirmation for my appointment:

Yes

Your e-mail*

Appointment date:*

time of your appointment*

Please, choose your Toro Dental Clinic*

Toro Dental Clinic Jean-Talon

Toro Dental Clinic Notre-Dame

Sex

Woman

Man

Date of birth:

Marital status:

Single

Married

Your Wheight:

Your Height:

I am a customer of Les Cliniques Toro *

Yes

Medical Insurance Number (Assurance Maladie):*

Expiration:*

Financial guardian (if different):

If a child, name of the parent:

Referred by:

INFORMATION ABOUT THE EMPLOYEE INVOLVED IN AN INSURANCE PLAN:

Name of the Insurance Company:

Plan number:

Number of section or division:

Certificate or identity number:

Name of the insured person:

Are you covered by an other insurance Plan?:

Yes

If yes, name of the company:

Plan number:

Number of section or division:

Certificate or identity number:

HELP US TO KNOW YOU BETTER:

Are you satisfied with the appearance of your teeth?:

Yes

worried about financial means required for a treatment?:

Yes

disappointed because you have to receive new treatments?:

Yes

Do you feel compelled to wear artificial dentures one day?:

Yes

Have you of fears in front of dentist?:

Yes

MEDICAL HISTORY

Are you currently under the care of a doctor?:

Yes

If yes, give the name of your doctor here:

Phone of your doctor ( with extension):

Currently taking medications or during last 6 months?:

Yes

If yes, please indicate which:

Are you pregnant?:

Yes

Are you taking oral contraceptives pills?:

Yes

HAVE YOU EVER SUFFERED OR ARE YOU SUFFERING FROM:

Cardiac problems (infarctus, angina, valves, respiratory)?:

Yes

Rheumatic fever?:

Yes

Prolonged bleeding?:

Yes

Anemia?:

Yes

Arterial tension?:

Yes

Frequents colds or sinus infections?:

Yes

Tuberculosis or pulmonary problems?:

Yes

Digestive problems?:

Yes

Stomach ulcer?:

Yes

Liver problems ( Hepatitis A, B, C or cirrhosis?):

Yes

Kidney problems?:

Yes

Venereal diseases (STDs)?:

Yes

Diabetes?

Yes

Thyroid problems?:

Yes

Skin diseases?:

Yes

Ocular problems ( eyes)?:

Yes

Arthritis?:

Yes

Epilepsy?:

Yes

Nervous?:

Yes

Frequent headaches?:

Yes

Dizziness, fainting?:

Yes

Ear problems?:

Yes

Hay fever:

Yes

Asthma?:

Yes

Smoker?:

Yes

Have you ever received radiotherapy or chemotherapy?

Yes

Acquired immune deficiency syndrome (AIDS)?:

Yes

Have you tested positive for AIDS?:

Yes

Do you have articular prostheses?:

Yes

Have you ever been hospitalized and / or undergone surgery other than dental?:

Yes

If yes, wich ones and when?:

Would you like to privatelly discuss with your dentist?:

Yes

DENTAL HISTORY:

last visit to the Dentist:

0-6 month

6-12 month

+ de 12 month

Have you ever received an oral hygiene demonstration?:

Yes

Have you ever received a Gum treatment?:

Yes

Have you had orthodontic treatment (braces)?:

Yes

Have you ever received a root canal treatment?:

Yes

Have you had fillings (repairs)?:

Yes

Crowns and/or bridges?:

Yes

Partial or complete prostheses?:

Yes

Dental surgery or extractions?:

Yes

Dental Implants?:

Yes

Dental radiographies?:

Yes

Others?

Yes

Are you human ?*

This field should be left blank

APPOINTMENTS