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زراعة الأسنان – الرئيسي
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Your Name (*)
Select appointment date
Your Age / Sex (*)
Your Email (*)
Your Mobile No. (*)
Adress (*)
1] What is the Problem you have encountered for which you are seeking dental appointment? (*)
PAIN
SWELLING
Difficulty in MOUTH OPENING
OTHERS
2] How do you Rate your painfrom 1 -10? (*)
One - Five
Six - Ten
3] ASSOCIATED SYMPTOMS IN BODY LIKE- (*)
FEVER
COLD AND COUGH
CHEST PAIN
DIFFICULTY IN SWALLOWING
DIARRHEA
4] WHAT IS THE RESULT OF YOUR TEST? (*)
Positive for Rapid test
Negative for Rapid test
Positive for RT- qPCR
Negative for RT- qPCR
5] What Test is done to Rule out COVID-19? (*)
RAPID TEST (IgM/IgG Antibody testing)(BLOOD TEST)
Real time POLYMERASE CHAIN REACTION ( RT-qPCR)(SWAB TEST)
None
6] MEDICAL HISTORY (*)
HIGH BP
THYROID PROBLEM
HEART AILMENT
KIDNEY DISEASE
ASTHAMA OR BREATHING PROBLEM
HIV/AIDS
DIABETES
ACIDITY(PEPTIC ULCER)
7] Are you Aware that children below age 15 and old aged above 50 years are prone for progression of COVID-19. (*)
Yes
No
8] Have you being taken for QUARANTINE / ISOLATION CENTRE? (*)
Yes
No
9] Have you being tested for COVID-19(CORONA VIRUS)? (*)
Yes
No
10] Do you have an organ transplant? (*)
Yes
No
11] Are you pregnant/feeding? (*)
Yes
No
12] List any other illness (*)
11] Mandatory NOTE for information to all the patients who are visiting DENTAL CLINIC
You should be Aware thatCOVID-19 (CORONAVIRUS)is presently PANDEMIC in the WORLD and has high chance of Cross Contamination in HOSPITALS and DENTAL CLINICS getting any procedure done in hospitals/Dental clinics carry high risk of TRANSMISSION of COVID-19,
Therefore, it is IMPERATIVE and is the responsibility of hospital and the patient to follow very strict ASEPTIC PROTOCOLand that necessitates the hospital to use lot of additional MATERIAL AND EQUIPMENT in the process.
Considering this special circumstance, only SELECTIVE TREATMENT is offered in the dental hospital presently based on EMERGENCY Condition, and treatment shall be under the discretion of the DENTIST to offer minimal treatment presently and in the due course of time, based on the situation of COVID-19 Rest of the treatment will be Guided and commenced.
You should be aware that only the patientis allowed into the HOSPITAL PREMISIS starting from ENTRY to EXIT Exceptions are only for those who are physically challenged or children below 18years.
(*)
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