Personal Details

First Name

Last Name

Date of Birth

Address

Referred By

Medical History

Family Doctor's Name

Doctor's Contact No.

Any other problem not listed above

WOMEN

Are you pregnant?

Are you nursing?

Any other Drug not listed above

Dental History & History of present illness

Dental Procedures done during last one year

What is your present complaint?

Have you ever experienced an adverse reaction during or in conjugation with a medical/dental procedure?

Yes

Informed Consent

I give my consent to any advised and necessary dental procedures, medication or anaesthetics to be administered by the attending dentist. I understand that long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene and regular recall visits. I have been explained the treatment procedure, possible complications and side effects in detail. I also declare that the above information provided by me is correct.

COVID-19 Pandemic Dental Treatment Consent

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing.

If I am an asymptomatic carrier or an undiagnosed patient with COVID 19, I suspect it may endanger doctors and clinic staff. It is my responsibility to take appropriate precautions and to follow the protocols prescribed by them.

I am aware that I may get an infection from the clinic or from a doctor, and I will take every precaution to prevent this from happening, but I will not at all hold doctors and clinic staff accountable if such infection occurs to me or my accompanying persons.

In case I or my attendant get the COVID 19 infection after the visit to the clinic, I will inform the clinic authorities at the earliest, so that appropriate tracking of the patients/attendants and clinic staff present on the day of my visit can be done.

I confirm that I am not presenting any of the following symptoms of COVID- 19 listed below
- Fever
- Shortness of Breath
- Loss of Sense of Taste or Smell
- Dry Cough
- Runny Nose
- Sore Throat

I understand the government recommends social distancing of at least 6 feet for a period of 14 days to anyone who has shown symptoms or tested positive.

I verify that I have not travelled outside of India in the past 14 days to countries that have been affected by COVID- 19.

I verify that I have not travelled domestic within India by commercial airline, bus, or train within the past 14 days.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to treatment completed during the COVID-19 pandemic.

I accept above terms & conditions.

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