Smilekraft Dentistry COVID 19 Disclosure Form
Email address *
Name *
First and last name
Your answer
Age *
Your answer
Sex *
Phone number *
Your answer
Residential Address *
Your answer
Did you have any symptoms of Fever, Cough, Sore throat and/or fatigue anytime during last 21 days? *
Required
If yes and possible, please explain the symptom and its intensity.
Your answer
Did you experience any difficulty in breathing anytime during last 21 days? *
Did you have any exposure to a known or suspected case of Covid19 patient in last 21 days? *
Are you residing in a locality that has been notified by the Government as a covid containment zone in last 21 days? *
Have you visited any other medical facility/hospital in last 21 days? *
If yes, please mention the reason
Your answer
Have you ever been tested for Covid19? *
If yes, please mention positive or negative
Your answer
The above information given by me is true to the best of my knowledge. I fully understand and acknowledge that withholding or mis-representation of any information is highly unethical and against the interest of larger population during this pandemic. *
I have been made aware that dental procedures create ultra-fine water spray that may transmit the Covid19 virus. I understand the Covid19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I also understand that, due to the contagious nature of the disease and characteristics of dental procedures, I have an increased risk of contracting the virus simply by being in a dental office as compared to staying at home, in spite of the best disinfection protocols applied in the dental clinic. *
I fully understand and acknowledge that I may be an asymptomatic carrier of the disease and hence will strictly comply with all safety precautions and protocols advised. In the eventuality of my testing covid positive at a later date, I will not hold Smilekraft Dentistry or any of its staff responsible for it. I hereby knowingly and willingly give consent to have my emergency/urgent dental treatment completed during the Covid pandemic. *
Date *
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A copy of your responses will be emailed to the address you provided.
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