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Your Name (*) Select appointment date Your Name (*) Your Email (*) Your Mobile No….

    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? (*)
    2] How do you Rate your painfrom 1 -10? (*)
    3] ASSOCIATED SYMPTOMS IN BODY LIKE- (*)
    4] WHAT IS THE RESULT OF YOUR TEST? (*)
    5] What Test is done to Rule out COVID-19? (*)
    6] MEDICAL HISTORY (*)
    7] Are you Aware that children below age 15 and old aged above 50 years are prone for progression of COVID-19. (*)
    8] Have you being taken for QUARANTINE / ISOLATION CENTRE? (*)
    9] Have you being tested for COVID-19(CORONA VIRUS)? (*)
    10] Do you have an organ transplant? (*)
    11] Are you pregnant/feeding? (*)
    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.
    (*)