Covid 19 Form 3 – Dentist in Quezon City | Emergency Dentist in Quezon City

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First Name

Last Name

Phone Number

Date / Time

Age

Sex

Male
Female

Address

Occupation

Temperature

In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID-19?

Yes
No

If the answer is YES, please state the exact location

In the past 14 days, have you or any member or your household has had any contact with any COVID-19 patient?

Yes
No

Have you or any household member have any history of exposure to any COVID-19 biological material (e.g. saliva)?

Yes
No

Have you had any history of fever for the last 14 days?

Yes
No

Have you had any symptoms in the last 14 days such as: cough, nausea, diarrhea, loss of taste, difficulty breathing, body ache, loss of smell, fever?

Yes
No

Urgent dental need in the last 14 days such as uncontrolled dental/oral pain, swelling, bleeding, infection, trauma?

Yes
No

I give my full consent to have dental treatment done to me in this time of pandemic caused by COVID-19 disease. (Enter Initial)

As explained by my dentist, the virus can be transmitted by contact through surfaces and that it can stay in the air for 5 to 72 hours. I am aware that it is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff. (Enter Initials)

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

I fully understand the risk that because of the nature of the virus, traveling to the clinic, the clinical procedures, and even by 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 liable. (Enter Initials)

I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contact tracing for the interest and safety of the community. (Enter Initials)

What is the Patient's or Guardian's Full Name

If guardian. Please provide relationship to patient

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