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Medical Form

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Accuel Patient area Medical Form

Dentistry is today a science that is an integral part of Medicine. In order to treat you safely and to ensure the best dental treatment, we need you to provide us with some essential information about your health, your medication and the condition of your teeth.

Therefore, we thank you for carefully answering the following questions. It should only take a few minutes and it will be of great help to us.

Of course, the information you give us will remain strictly confidential. We will review it together during your consultation and discuss it in detail.

    Date of birth

    Wrong date.

    Name

    First name

    Profession

    Mailing address

    Mobile phone/fixed line

    Invalid number.

    E-mail address

    Email address is not valid.

    Name of your attending physician

    When was your last medical examination?

    Do you have a particular health problem to report to us ?

    Please check each of the following diseases or conditions you may have had in the past or currently have: (Answers will be completed during the interview with the Dentist).

    This field is required.

    Have you ever had abnormal bleeding during a procedure or accident ?

    Have you had radiation therapy ?

    Are you currently taking any medications ?

    If yes, which ones :

    This field is required.

    Are you allergic to any products or medications ?

    If yes, which ones :

    This field is required.

    If you think you have any other illness or condition not listed above that would help us treat you in the best possible way, please specify it here

    Are you a smoker ?

    If yes, number of cigarettes/day

    This field is required.

    Ms, Miss, are you pregnant?

    This field is required.

    If yes, how many months old

    This field is required.

    Are you taking any treatment for osteoporosis or other bone disease ? (Didronel, Clabostan, Lytos, Skelid, Aredia, Fosamax, Fosavance, Actonel, Bonviva, Bondranat, Zometa, Aclasta) ?