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Confidential medical-dental questionnaire - Centre Dentaire Cousineau

Personal Information

For the terms and conditions of direct sending to private insurance, please refer to our policy which can be found in the Welcome email from our dental center.

Medical history


You can send your list of medications to :


or by fax: 450-676-8433

Allergy or manifestation with products containing :

Conditions médicales

Please check Yes or No for each current or past condition 

Other aspects


Dental information

Oral habits

Cousineau Dental Center policy

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

Signature :