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Screening/Disclosure Form for Plastic Surgery/Dental Patients During Covid-19 Epidemic

Name of Patient:
Your Full Name
Field is required!
Field is required!
Gender:
  • - select a gender -
  • Male
  • Female
- select a gender -
Field is required!
Field is required!
Age:
-
+
Please fill
Please fill
Phone Number:
Enter phone number
Please fill
Please fill
Date:
Select a date
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Field is required!
Address:
Enter your address
Please fill
Please fill

Covid 19 Screening

Question 1:
Do you have any symptoms of Fever, Cough, Sore throat and /or fatigue anytime during last 21 days?
Field is required!
Field is required!
Question 2:
Did you experience any difficulty in breathing anytime during last 21 days?
Field is required!
Field is required!
Question 3:
Do you have any exposure to a known or suspected case of Covid-19 patient in last 21 days?
Field is required!
Field is required!
Question 4:
Have you visited any other medical facility /hospital in last 21 days? If yes, for what reason?
Field is required!
Field is required!
Question 5:
Are you residing in a locality that has been notified by the government as a COVID containment zone in last 21 days?
Field is required!
Field is required!
Question 6:
Have you ever been tested for Covid-19 ? If yes, give details
Field is required!
Field is required!
Question 7:
Have you installed the Aarogya setu app?
Field is required!
Field is required!

The above information given by me is true to the best of my knowledge. I fully understand and acknowledge that withholding or misrepresentation of any information is highly unethical and against the interest of the larger population during this pandemic.


I have been made aware that procedures create an ultra-fine spray that may transmit the Covid-19 virus. I understand the Covid-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I also understand that, due to the contagious nature of the disease and characteristics of the procedures, I have an increased risk of contracting the virus simply by being in a clinic in spite of the best disinfection protocols applied.


I fully understand and acknowledge that I may be an asymptomatic carrier of the disease and hence will strictly comply with all safety precautions and protocols advised. In the eventuality of my testing COVID positive at a later date, I will not hold the Clinic provider/staff/set-up responsible for it. I hereby knowingly and willingly give consent to have my procedure completed during the COVID pandemic.


Patient Consent
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