SmilePH Appointment Form

SmilePH Dental Center

This form is a requirement before scheduling your appointment. Please answer this form honestly.
Name*

First NameLast Name
Age*
Gender*

MaleFemale
Address*

Street Address

City
Contact Number*
Occupation*
Email*
example@example.com
Reffered By:
What is your Dental Complaint? *
Dental Complaint
Dentist
Request Appointment*
1. Are you fully vaccinated?*

YesNo

2. Have you had any symptoms in the last 14 days such as:*

	Yes	No
Cough
Nausea
Loss of smell
Fever

INFORMED CONSENT*

	Yes	No
I give my fill consent to have dental treatment done to me or my child(ren) in this time of pandemic caused by COVID-19 disease
I am aware that the viirus can be transmitted by contact through surfaces and that it can be infective for 5 to 72 hours. I am aware that this is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff.
I recognize that the clinic is adhering to the strictest infection control protocols for my protection as such, I agree to cover the fees that this entails.
I fully understand the risk that because of the nature of the virus, by simply leaving my home, travelling to the clinic, the clinical procedures, and even by simply staying in the dental clinic, there is a chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office liable.
I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contract tracing for the interest and safety of the community.

For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form:

Clear
Please sign your signature here
After submitting the form, please wait for our dental team to review your inquiry or call 0951-591-1913.

Thank you so much and God bless!
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