Smilekraft Dentistry COVID 19 Disclosure Form
Email *
Name *
First and last name
Age *
Sex *
Phone number *
Residential Address *
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.
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
Have you ever been tested for Covid19? *
If yes, please mention positive or negative
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 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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