Medical Form

In order to accommodate you, the medical form that we ask you to complete when you arrive at the clinic is also available online. Please make sure that the required fields are completed correctly.

Personnal information


Medical questions

Have you or have you ever had any of the following conditions

Have you ever taken? :

Are you allergic to or have ever had a reaction to?

Are you pregnant or is there a possibility of pregnancy? *

Are you nursing? *

Do you take an oral contraceptive? : *

Are you currently under the care of medical specialist?*

Have you been seriously sick or hospitalised in the past 5 years? *

Have you ever had complications after a dental or medical treatment? *

Do you have any inflamed or non-cured internal or external mouth injuries? *

Do you have prostheses for any joints? *

Do you have an artificial cardio-vascular valve or any vascular implant? *

Do you currently smoke or have you smoked in the past? *