COVID-19 Pre-Appointment Form

Pre-Appointment Screening Form
Laroco | Clínica Dental is taking precautions to avoid further spread of the COVID 19 virus. In light of this, we have instituted additional guidelines and protocols to ensure your safety.

1. The clinic will be strictly BY APPOINTMENT ONLY. No Walk Ins.

2. We require ALL PATIENTS to wear a mask upon entering the office.

3. Bringing of companions are NOT allowed, unless necessary, and only limited to 1 per patient. It is advised that they wait outside the clinic.

4. Maintain social distancing in the reception area for essential companions if they cannot wait in a vehicle or outside the clinic.

5. Please come on time. We try to allot enough time for your procedure and in between patients for proper cleaning and disinfection of the operatory. Any delays will affect succeeding appointments.

6. We will require hand sanitizing and recording of temperature as you enter the clinic.

7. Please fill out the pre-appointment screening form.

Thank you!
Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (0000) 0000-000.
Email
example@example.com
MaleFemale
Age*
Address

Street Address

State / Province

Postal / Zip Code
Occupation*
MEDICAL HISTORY
DiabetesCancer TreatmentHeart DiseaseThyroid DiseaseEndocrine DisorderAsthmaEpilepsyHepatitisHigh Blood PressureOther
TRAVEL HISTORY

Please disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus
YesNoOther
IF YES, when did you arrive in the Philippines?
IF YES, please specify country/ies or city/ies visited.
YesNo
YesNo
IF Yes, When?
YesNo
YesNo
Cough / UboShortness of Breath / Kapos sa PaghingaFever / LagnatChills / PaggiginawFatigue / Lubos na pagodMuscle Aches / Pananakit ng katawanDiarrhea / PagtataeVomiting / PagsusukaHeadache / Pananakit ng uloSore throat / Pangangati ng lalamunanNew loss of taste or smell / Kawalan ng panlasa at pang-amoyMalaise / Masama ang pakiramdamNausea / PagkahiloNo symptoms in the last 14 days
I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief.*

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Pre-Appointment Screening Form

MEDICAL HISTORY

TRAVEL HISTORY