Simpliciteeth Dental Clinic Pre-screening Health Declaration Form

HEALTH DECLARATION FORM

Please answer the following questions truthfully to enable us to ascertain whether we can attend to you immediately or defer your treatment after a reasonable period so as not to risk our staff and other patients. This is in accordance with the Department of Health and Philippine Dental Association.

(Pakisagot lamang ang mga katanungan ng makatotohanan para sa kaligtasan ng ating staff at ng iba pang mga pasyenteng papasok sa Dental Clinic.)
Complete Name*

First NameLast Name
Age *
Date of Birth *

MonthDayYear
Address *

Complete Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*

StudentHealthcare workerOther
Contact number*
Facebook / Messenger Name*
E-mail
example@example.com
Please be reminded that under Republic Act No. 11332, you are required to provide truthful information about your health condition and possible exposure. Non-cooperation is punishable by law.

(Ayon sa Republic Act No. 11332, kailangang ilahad ang lahat ng impormasyon patungkol sa iyong kalusugan at sa posibilidad ng "exposure" sa COVID-19. Ang paglabag nito ay may karampatang parusa.)
Have you tested for COVID-19? (Ikaw ba ay sumailalim sa COVID-19 testing?)*

Yes, I tested negative (Oo, ako ay negatibo sa test)No, I haven't tested yet (Hindi pa ako nagpapatest)Yes, I tested positive (Oo, ako ay positibo sa test)
Have you had fever or other flu-like symptoms (e.g. cough, sore throat, colds, headache, loss of smell and taste, muscle pain, difficulty of breathing) within the last 14 days? (Ikaw ba ay nagkaroon ng lagnat o alinman sa mga sintomas na nakalahad tulad ng ubo, namamagang lalamunan, sipon, sakit ng ulo o hirap sa paghinga sa nakalipas na 14 araw?)*

Fever (Lagnat)Cough (Ubo)Sore throat (Namamagang lalamunan)Colds (Sipon)Headache (Sakit ng ulo)Difficulty of breathing (Hirap sa paghinga)Muscle pain (Pananakit ng kalamnan)Loss of smell and taste (Pagkawala ng pang-amoy at panlasaNoneOther
Have you been in close contact with a COVID-19 positive patient, a person under investigation (PUI), a person under monitoring (PUM), or with someone who arrived from abroad within the last 30 days? (May nakahalubilo ka bang positibo sa COVID-19, person under investigation (PUI), person under monitoring (PUM), o taong kadarating pa lamang galing ibang bansa sa nakalipas na 30 araw?)*

COVID-19 positivePUIPUMSomeone who arrived from abroadNone
Have you attended a mass gathering, reunion, or parties within the last 30 days? (Ikaw ba ay dumalo sa mga pagtitipon sa nakalipas na 30 araw?)*

YesNo
Have you visited any country or city outside Metro Manila within the last 30 days? (May pinuntahan ka bang ibang bansa o lungsod sa nakalipas na 30 araw?)*

YesNo
If yes, kindly specify country or city and when. (Kung oo, saan at kailan)
Are you taking any medications? (May iniinom ka bang gamot sa kasalukuyan?)*

YesNo
If yes, kindly let us know what medications.(Kung oo, ano-ano ang mga ito)
If you have a COVID-19 clearance certificate kindly upload it here (Kung ikaw ay mayroong COVID-19 clearance certificate maaari lamang na iupload dito)

Cancelof
Kindly upload a photo (Mag-upload ng iyong larawan)*

Cancelof
E-Signature. I hereby confirm that the information provided above is true, accurate, and complete. I further understand that ANY FALSE STATEMENTS MAY BE PUNISHABLE BY LAW. (Kinukumpirma ko na ang mga impormasyong aking ibinigay ay totoo, tama, at kumpleto. Nauunawaan ko na ang PAGBIBIGAY NG HINDI TOTOONG KASAGUTAN AY MAY KARAMPATANG PARUSA SA ILALIM NG BATAS.) *

Clear
Date today*

MonthDayYear
APPOINTMENT SCHEDULE

We will only give 15 minutes grace period. Late patients will not be accommodated, unless there is a vacancy of slot after his/her scheduled time. If you wish to cancel your appointment kindly notify us 1 day prior your scheduled appointment. NOTE: Chosen schedule is not yet final - due for assessment.

(Magbibigay lamang kami ng 15 minutong palugit, kung hindi makakarating sa takdang oras ay kinakailangang ipa re-schedule ang appointment sa ibang araw. Kung nais namang kanselahin ang appointment, maaari lamang na sabihan kami 1 araw bago ang iyong scheduled appointment. NOTE: Pag-aaralan pa namin ang sinumiteng sagot sa form bago kumpirmahin ang iyong napiling schedule)
Appointment*
What procedure are you appointing for?*

Orthodontic adjustment (Braces adjustment)Extraction (Bunot)Prosthodontics (Denture/Pustiso)ConsultationOther
Please be advised that there will be an additional infection control fee of 400.00 for every appointment.
Please wait for our confirmation of your appointment.

For any other concerns, kindly message us at our Facebook page SIMPLICITEETH DENTAL CLINIC.
Should be Empty:

Please wait for our confirmation of your appointment.