Dr Narayana's oral care studio ; Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name

First NameLast Name
Phone number
Present residential Address
Body temperature noted at the clinic
SpO2 Levels noted at clinic
Have you travelled abroad or within india during 2020?

YesNo
Name of the area(s) visited
Country, State, City
Dates of travel
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?

YesNo
If yes, Your relationship with them and your last contact date with them

Please state whether you've experienced/are experiencing the following

	Yes	No
Fever in last 28 days
Cough in last 28 days
Shortness of Breath in last 28 days
Persistent Pain in the Chest in last 28 days
New Onset Loss of Smell
New Onset Loss of Taste
History of Hospitilzation in the last 28 days with the above Symptoms

Are u residing in a locality notified by government as a containment zone in last 21 days?

NoIf yes when?
Will you adhere and cooperate with the told present covid19 health care guidelines?

YesNo
I acknowledge that the information I've given is accurate and complete.

I acknowledge that the information I've have given is true, accurate and complete.

I understand that COVID -19 viral infection is a droplet infection and the carriers can be asymptomatic during the incubation period, hence if I contract or get infected during our visit to this clinic inspite of following all self-protection measures such as a face mask, sanitisation and physical distancing. I shall reserve no right for any legal indemnity or legal action against this clinic, staff or the clinic treating doctor.
Appointment preferred
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: