DECLARATION FORM FOR COVID-19

We are looking forward to seeing you soon at Braces & Smiles. Our Dental Association has mandated that we screen the patients through a questionnaire, before any appointment. Kindly fill out the form below so we can confirm your appointment. Thank you for your cooperation.

Choose your Branch: JuhuKandivaliNerul



GenderFemaleMale





Covid–19 Questionnaire

1) Has the patient previously been diagnosed with Covid-19? (Or Do you think the patient has/ had Covid-19?
YesNo

2) If the patient had Covid-19, was he/she confirmed negative with a test?
YesNoNot Applicable

3) Does the patient have any of the following symptoms:
- Fever
YesNo
- Dry Cough
YesNo
- Sneezing
YesNo
- Sore throat
YesNo
- Fatigue (feeling tiredness)
YesNo
- Shortness of breath
YesNo
- Difficulty in breathing
YesNo
- Muscle pain
YesNo
- Any other flu-like symptoms
YesNo
- Diarrhoea
YesNo

4) Did the patient have exposure to a confirmed Covid-19 case or to a suspicious patient in the last two weeks?
YesNo

5) Does the patient reside in a containment zone?
YesNo

6) Has the patient travelled outside the country in past 30 days?
YesNo

7) Has the patient travelled inside India to other cities in past 15 days?
YesNo

8) Is the patient over 65 years of age?
YesNo

9) Does the patient have high blood pressure?
YesNo

10) Does the patient have diabetes?
YesNo

11) Does the patient have respiratory problems?
YesNo

12) Does the patient have any autoimmune disorders?
YesNo

The above information is true to the best of my knowledge. I understand that withholding any information is unethical and against the interests of the global population fighting this pandemic.

The patient will be going to Braces & Smiles for dental treatment. The orthodontist / dentist reserves right to treat /defer /refer me accordingly. If I happen to be an asymptomatic carrier or an undiagnosed patient with Covid-19 disease, I suspect it may endanger the dentist and the clinic staff.
It is my duty and responsibility to take appropriate precautions and follow the protocols prescribed by them.
I also know and understand that I may already be an asymptomatic carrier/ undiagnosed Covid-19 positive patient/ may get infected due course of time after my visit to the dental clinic and I will not hold the doctors or the staff of the clinic responsible for any future diagnosis of Covid-19 with me or my accompanying person. The Doctor May prescribe you a COVID test if there are concerns regarding your symptoms as per the govt guidelines and left at the discretion of the doctor. The above terms and conditions have been read by me / have been explained to me in my native language to my complete satisfaction.

I agree to all terms and conditions mentioned above. I verify, confirm and agree to be held accountable, regarding the details given by me which I state are true to the best of my knowledge.