Dr. Rajen's Dental Clinic

Health Screening Form

Dear Patient,

Welcome to Dr. Rajen's Dental Clinic

In the wake of the unprecedented situation created by the COVID-19 pandemic, it is our collective responsibility to prevent the spread of the virus and reduce the risk of exposure in our community. Your time and assistance in filling this questionnaire is integral to our efforts in containing COVID-19 and is deeply appreciated.

Note: Information captured is used for contact tracing if required and emergency contact

Full Name

Personal Contact No:

Emergency Contact Name:

Emergency Contact No.

Appointment Date:

Appointment Time.

Are you experiencing any of the symptoms listed below? Please indicate as many as applicable.

Fever

Dry Cough

Sore Throat

Runny Nose

Headaches

Breathing Difficulty or Shortness of Breath

Body Aches

No Symptoms

Have you been in contact with a confirmed COVID -19 case in the past 14 days?

Yes

Have you been asked to go for home quarantine by an authority or medical practitioner?

Yes

Have you tested Positive for COVID -19?

Yes

If you have been a confirmed COVID-19 Patient, kindly mention test date

Have you been to any red zone / affected countries or area(s) in the past 14 days?

Yes

If yes, please indicate the affected country(s) or area(s)

Patient Allergic to any medicine?

Yes

Suffering from Hypertesion, Diabities, Thryoid?

Yes

Blood thinner or any other medicines taken?

Yes

Consent

Work to be done: I understand that I will be going through the following or any other treatment as diagnosed by the doctor:
- Fillings
- Bridges
- Crowns
- Extractions
- Root Canals
- Gum Treatment
- Removable Partial/Complete Denture
- Dental X-Rays
- Orthodontia
Drugs and Medications: I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).
Changes in Treatment Plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.
Removal of Teeth: Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.) and I authorize the dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or in rare occasions may be permanent; or fractured jaw.
I understand that all the treatment will be done by Dr Rajen Gordhandas or his/her associate in the clinic

Patient Signature

Dr. Rajen's Dental Clinic, Matru Mandir, Tardeo Road, Grant Road, Mumbai - 400007 Mob: +91 9322232133