Dear [[Title]] [[PatientName]] ,
Your safety is utmost important to us. We follow the highest standards of safety precautions and
protocols. Kindly reply to this mail and fill out the following questionnaire to the best of your
knowledge. If the answer to any of these questions is Yes, please provide detailed information. This
will let us take best possible care for you.
Please do not hesitate to call us if you have any queries.
Thank you.
Covid-19 Questionnaire Yes / No
(all questions must be answered)
1 Did you have any symptoms of fever, cough, sore throat, difficulty in breathing,
and/or fatigue anytime during last 21 days? If yes, please provide details in Notes
area below.
2 Did you /your family members/cohabitants travel within / outside the country or
outside state anytime during last 21 days? If yes, please specify dates & names of
places in Notes area below.
3 Did you have any exposure to known or suspected cases of Covid-19 patients in last
21 days?
4 Did you visit any other medical facility / hospital in last 21 days? If yes, please specify
dates, names of hospital/clinic, reason for visit in Notes area below
5 Have You Remained in Quarantine or Are you residing in a locality that has been
notified by the government as a Covid containment zone?
6 Have you ever been tested for Covid-19? If yes, please specify following.
Date of testing: Result:
7. Have you recently participated in any gathering ?
8. Any other medical history?
9. Have you taken any medication before visiting the dental clinic?
Declaration:
1. 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.
2. 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.
3. 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.
4. 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.
5. I confirm that neither I nor any of my family members are presenting any of the following symptoms
of COVOID-19 listed below:
a - Fever
b - Shortness of Breath or difficulty in breathing
c - Loss of Sense of Taste or Smell
d - Dry Cough
e - Runny Nose &/or Sneezing
f - Sore Throat
g- Body Aches/Pain
6. 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.
7. I verify that I /anyone in my family have not travelled outside of India in the past 14 days to
countries that
have been affected by COVID-19.
8 I verify that I have not travelled domestic within India by commercial airline, bus, or train
within the past 14 days.
9. 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. If I hide my facts
and relevant details and because of my knowing or unknowing behaviour or action the
clinic staff gets infected, I may be held responsible in the court of law.
10. I have been made aware that dental procedures create ultra –fine water spray that may transmit the
COVID-19
virus. 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.I also understand that due to the contagious
nature of the disease & characteristics of dental procedures, I have an increased risk of contracting the
virus simply by being in a dental office inspte of the best disinfection protocols applied.
11. I fully understand & 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 the dental service provider/staff/dental setup responsible
for it.
12. I hereby knowingly and willingly give consent to have my emergency/urgent dental treatment
completed during the COVID pandemic.
Signature of Patient Staff Signature
Date
Notes:
