平特五不中
平特五不中
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Faculty of Dental Medicine and Oral Health Sciences
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Screening Application
Patient Information
Last Name
*
First Name
*
Email
*
Address
*
Street, Apartment, City, Province, Postal Code
RAMQ - medicare number
Languages spoken
*
English
French
Other
Telephone (home)
*
Telephone (work)
Cell
Sex
*
Female
Male
Date of birth
*
dd/mm/yy
Best time to call
Patient Expectations and History
Is this your first visit to the MUHC Dental Department?
*
Yes
No
Not sure
If no, when was your last visit?
When was the last time you saw a dentist? What treatment was received?
Do you have private dental insurance?
*
Yes
No
Do you have dental coverage from Social Assistance (Welfare)?
*
Yes
No
Are you missing teeth?
*
Yes
No
If yes, how many?
How did you hear about our Dental Clinic?
*
Do you accept that this is a teaching clinic and that treatment takes twice as long compared to a private office?
*
Yes
No
Are you available during our office hours: Monday to Friday 8:30am-4:30pm?
*
Yes
No
Do you want to treat all your dental needs? (Replace all missing teeth/repair all teeth needing treatment?)
*
Yes
No
Replace all missing teeth/repair all teeth needing treatment?
Do you want to treat some of your dental needs?
*
Yes
No
Are you comfortable receiving treatment from many different dentists in a learning environment?
*
Yes
No
Why do you want to receive treatment in our department?
*
Financial
Pain
Specialty service
For a specific dentist
Other
If applicable, which service/dentist/other reason brings you here?
Do you have a referral from another dentist?
Yes
No
Please upload a copy of the referral and radiographs, if applicable
Files must be less than
2 MB
.
Allowed file types:
gif jpg jpeg png
.
Treatments Requested
*
Cleaning
Fillings
Gum treatment
Crowns or caps
Replacement of missing teeth
Complete dentures
Partial dentures
Root canal treatment
Implants
Permanent bridges
Is there any other information you would like to add?
In case of emergency, please present yourself to the 聽Emergency Department of the 聽Montreal General Hospital
Leave this field blank
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