Register Patient

First Name :*

Last Name :*

Birthdate :

Gender :
Male   Female

Email :*

Contact No.:*

Address :

Appointment Details

I am visiting alone I have a companion

Preferred Date :

Preferred Time From:

Preferred Time To:

Reason for Visit :*

Companion Details

You need to fill in this information if someone needs to accompany you.

Name :*

Age :*

Contact No.:*

Email:

Gender :
Male   Female

Patient Screening Questions

1. Do you or your companion have fever or have you felt hot or feverish recently (14-21 days)?
Yes   No

2. Are you or your companion having shortness of breath or other difficulties breathing?
Yes   No

3. Do you or your companion have a cough?
Yes   No

4. Do you or your companion have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes   No

5. Are you or your companion in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Yes   No

6. Are you or your companion over 60 years of age?
Yes   No

7. Do you or your companion have a heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes   No

8. Have you or your companion travelled in the past 14 days to any country affected by COVID-19?
Yes   No

Patient Consents

I give my full consent to have my dental treatment during this COVID-19 pandemic.

The virus can be transmitted by contact through surfaces and that it can stay in the air for 5-72 hours. I am aware that it is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatments are limited to urgent and emergent care only to protect me, other patients and the dental staff.

I recognize that the clinic is adhering to the strictest infection control protocols for my protection and such, I agree to cover the fees that this entails.

I fully understand the risk that because of the virus nature, going to the clinic, the dental treatments, and simply staying in the dental office, I have a higher chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office and its staff responsible.

I also give my full consent in accordance to the Government rules, my identity shall be revealed for possible contact tracing for the interest and the best safety of the community.

Acknowledgement

I hereby acknowledge that I have TRUTHFULLY and HONESTLY answered the questions and I have read and fully understood the guidelines and patient consent form.