COVID-19 Screening Form - Smile Station
This patient screening questionnaire is designed to ascertain possible exposure to severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), which causes the disease COVID-19. This screening process needs to be implemented on the preceding day of the appointment to help confirm your appointment.

To know about the Biosafety measures implemented at Smile Station, please visit
Email address *
Your Name: *
Phone number: *
Date of form submission: *
Do you currently have (or have you experienced) any of the following symptoms in the past 21 days: *
Fatigue (feeling tired)
Altered or loss of taste/smell
Trouble/difficulty in breathing
Shortness of breath, chest tightness
Bluish lips or face or toes
Muscle pain
Sore throat
Tummy upset/ diarrhoea
Personal Health Update *
I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by governmental health agency. *
I understand the novel coronavirus causes the disease known as COVID-19 and the virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I also understand that I may be a subclinical or asymptomatic carrier or an undiagnosed patient of COVID-19 and endanger doctors and clinic staff. Hence it is my responsibility to take appropriate precautions for myself of safe distance, not to touch, wash/ sanitise hands, not to cough or sneeze unprotected and to follow the prescribed protocols. *
I understand that the doctors and the staff have taken all appropriate safety measures to protect and prevent the transmission of the virus in the clinic. I, understand that due to the visits of other dental patients, the characteristics of the novel coronavirus and the characteristics of dental procedures, that I have an elevated risk of contracting the novel corona virus simply by being in a dental clinic and I will not hold doctors and clinic staff accountable, if such infections occurs to me or my accompanying person. *
I understand that while the doctors and the staff have adhered to utmost safety precautions to insure highest levels of safety, it comes with a price. A sum of ₹400 is applicable as "Biosafety Charges" per patient per visit to facilitate the same, till the COVID-19 pandemic prevails. *
The high risk category includes diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over age 65 *
I understand that any form of domestic/ international travel or use of commercial transport or being part of gatherings and community events significantly increases my risk of contracting and transmitting the novel coronavirus and require self-isolation for 14 days from the date of such involvement. *
I understand that the Ministry of Health and Family Welfare, has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment. *
I verify the information I have provided on this form is truthful and accurate and agree to undergo the dental treatment as advised by the treating doctor. *
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