COVID-19 PRE-SCREENING FORM
Please answer the following questions to enable us to ascertain whether we can attend to you immediately or defer your treatment after a reasonable period so as not to risk other patients and our staff. This is in accordance with Department of Health and Philippine Dental Association. Rest assured that this questionnaire will be confidential.
Name
*
Last Name
First Name
Age
*
Address
*
Complete Address
Contact Number
*
Facebook / Messenger Name
*
Email
example@example.com
Please be reminded that under Republic Act No. 11332, you are required to provide truthful information about your health condition & possible exposure. Non-cooperation is punishable by law.
Have you tested for Covid-19?
*
Yes, I tested negative.
No, I haven’t tested yet.
Yes, I tested positive.
Have you had fever or other flu-like symptoms (eg. cough, runny nose, sore throat, headache, shortness of breathe) within the last 14 days?
*
Fever
Cough
Runny Nose
Sore throat
Shortness of breath
None
Have you been in close contact with a COVID-19 positive patient, a person under investigation (PUI), a person under monitoring (PUM), or with someone who arrived from abroad within the last 30 days?
*
Covid-19 positive
PUI
PUM
Someone from abroad within the last 30 days
None
Have you attended a mass gathering, a reunion, or parties within the last 30 days?
*
Yes
No
Have you visited any country or city outside Metro Manila within the last 30 days?
*
Yes
No
If yes, kindly specify the country or city.
Are you taking any medications?
*
Yes
No
If yes, kindly let us know what medications.
Electronic Signature: By signing in the box below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge:
*
Appointment Schedule
Please note that we will only give 15 minutes grace period. Late patients will not be accommodated.
Appointment
*
What procedure are you appointing for?
*
Orthodontic Adjustment (Braces Adjustment)
Extraction (Bunot)
Prosthodontics (Dentures/Pustiso)
Root Canal Treatment
Check-up
Other
Please wait for our confirmation of your appointment.
For any other concerns, contact us at 0916-366-2948.
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