Patient's Dental History and Consent Form

Consulting Patient's Details*

First NameLast Name

Email*

example@example.com

Age*

Sex*

MaleFemaleOther

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Today's Date*

Date

Medical Condition*

What is your main complaint or symptom ? Please mention the duration of each complaint / symptom.*

Have you taken treatment for this condition previously ?*

Any previous medication for other conditions ? (e.g. Blood Thinners)*

Attach (photos of) any previous prescriptions, Xray, OPG

Browse Files

Are you allergic to any medication(s) ? Please mention the name of the medicine.*

Was there any COVID-19 infected patient in your residence ? If yes, then do mention if you were in self quarantine for 14 days*

Residence Type*

IndividualApartment / SocietyOther

Were you residing at the same residence within the past 2 months ? If not then mention the temporary address and also mention the number of days you resided in the temporary address. Also mention the type of residence as mentioned above.*

Have you travelled anywhere outside your city in the last two months ?*

Did you come in contact with any COVID-19 patient in the last month ?*

I, knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. 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. Dental procedures create water spray. It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.

I am aware as per Government Health Guidelines, under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth.

I confirm I am seeking treatment for a condition that meets the criteria.
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 verify that I have not traveled within or outside the country in the past 14 days to countries that have been affected by COVID-19.
I verify that I have not been identified as a contact of someone who has been tested positive for novel coronavirus or been asked to self-isolate by government health agency.
I am aware that the clinic is taking all infection control precautions and i will not hold Doctor responsible for any untoward incident during the treatment.
I verify that the information I have provided is truthful and accurate. I knowingly and willingly consent to have the emergency dental treatment completed during the COVID-19 pandemic.

Name*

Date*

Signature

Dr. Jagdish TD

www.drjagdishtd.com

COVID-19 Pandemic Emergency Dental Treatment Consent Form