Online pre-admission

Name: Cabinet Dentaire Dr Laura Bernal
Address: 4 Rue Clemenceau, Albertville, Auvergne-Rhône-Alpes, 73200, FR
Telephone: +33 4 79 37 02 19
Price range: €€

Before your first appointment, please fill in this medical questionnaire. Your answers are sent to the practice and prepared in advance — saving you time in the chair. For an emergency, call +33 4 79 37 02 19.

Language :

1. Your details

First name *

Last name *

Date of birth

Phone

2. Reason for your visit

What brings you in?

This is an emergency (pain, trauma, swelling)

Current pain level

NoneVery high

Last visit to a dentist

3. Medical history

Tick anything that applies to you (this matters for your safety):

Heart conditionHigh blood pressureDiabetesAnticoagulants / blood thinnersAllergy to an anaestheticRespiratory problems (asthma…)EpilepsyHepatitis / liver diseaseKidney diseaseImmune deficiencyBisphosphonate treatmentCancer / chemotherapy / radiotherapy

Other health conditions

Allergies (medication, latex, metals…)

Medication you currently take

SmokerPregnant or breastfeeding

4. Documents (optional)

Add photos of the affected area, an old X-ray or a prescription (max 6).

📎 Add photos

I allow the practice to store this information in my medical record, in compliance with medical confidentiality and GDPR.

* Required fields

Cabinet Dentaire Dr Laura Bernal — your medical data is processed in compliance with medical confidentiality and GDPR.

Cabinet Dentaire Dr Laura Bernal

Cabinet dentaire à Albertville (Savoie). Notre équipe vous accueille sur rendez-vous pour tous vos soins.