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I would like to come to this office

I agree to be informed of the latest news available in the dental office (No obligation, can be cancelled at any time).

If I am a minor, please have my legal representative present:

My dental expenses are covered by :

Myself A social service

If it is a social service, what is its name?

Do you have supplemental dental insurance?

Yes No

If so, what is its name?

Are you taking any medications?

Yes No

If so, for:

Do you have any allergies (latex, medication, other)

Yes No

Have you encountered a heart problem (heart valve, endocarditis, malformation, murmur)?

Yes No

Do you wear prosthetic material? (Plate, screws, pacemaker)

Yes No

If so, since then:

Less than one year More than one year

Do you suffer from diabetes?

Yes No

Have you had radio or chemotherapy?

Yes No

If so, at what level?

When will it happen?

Right now In the past

Are you pregnant?

Yes No

How important is your oral health to you?

Large Low

When was your last visit to the dentist?

More than two years More than one year A few months

Do you have teeth that have broken in the past?

Yes No

Does food get stuck between the teeth?

Yes No

Are you satisfied with the alignment of your teeth?

Yes No

Do you like your smile?

Yes No

Do you have recurring pain or discomfort? (Tinnitus, headaches, shoulder/knee pain, other)

Yes No

How did you find out about PanaDent?

Relations Google Social networks

Reasons for the consultation

I authorize my treating dentist to transmit to any person, institution or other intervening party the data necessary for the realization of my treatment. I also authorize the transmission of data relating to the invoicing and collection of the fees due for the medical-dental services I have received (Caisse pour médecin-dentistes SA and EOS Suisse SA). I agree to show up on time for consultations and to cancel an appointment at least 24 hours in advance, failing which I may be charged for it. Cancelled appointments are reasonably limited. PanaDent reserves the right to stop taking care of me in case of repeated breaches. We hope you enjoy your visit and remain at your disposal.

By checking this box, I certify that all information provided is true and complete and agree to share it with PanaDent

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