Banaag Dental: Screening Form for Triage
This form is a requirement before scheduling your appointment. Please answer this form honestly.
Name
*
First Name
Last Name
Sex
*
Male
Female
Age
*
Address
*
Street Address
City
Occupation
*
Contact Number
*
Body Temperature (in Celsius)
Kindly take your temperature and enter the results here
1. In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID 19?
*
Yes
No
1.1 IF YES: Please state the exact location
IF NO: Skip question
2. In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient?
*
Yes
No
3. Have you or any household member have any history of exposure to any COVID-19 biological material (eg. saliva)?
*
Yes
No
4. Have you had any history of fever for the last 14 days?
*
Yes
No
5. Have you had any symptoms in the last 14 days such as:
*
Rows
Yes
No
Cough
1
2
Nausea
3
4
Diarrhea
5
6
Loss of taste
7
8
Difficulty breathing
9
10
Body Ache
11
12
Loss of smell
13
14
Fever
15
16
6. Urgent dental need question for the last 14 days such as:
*
Rows
Yes
No
Uncontrolled dental/oral pain
17
18
Swelling
19
20
Bleeding
21
22
Infection
23
24
Trauma
25
26
7. Have you had any COVID-19 test?
*
Yes
No
7.1 IF YES: When was the date of last test?
-
Month
-
Day
Year
IF NO: Skip question
7.2 IF YES: What was the type of test used?
IF NO: Skip question
7.3 IF YES: What was the result of the test?
Positive
Negative
Not yet determined
IF NO: Skip question
INFORMED CONSENT
*
Rows
Yes
No
I give my fill consent to have dental treatment done to me or my child(ren) in this time of pandemic caused by COVID-19 disease
27
28
I am aware that the viirus can be transmitted by contact through surfaces and that it can be infective for 5 to 72 hours. I am aware that this is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff.
29
30
I recognize that the clinic is adhering to the strictest infection control protocols for my protection as such, I agree to cover the fees that this entails.
31
32
I fully understand the risk that because of the nature of the virus, by simply leaving my home, travelling to the clinic, the clinical procedures, and even by simply staying in the dental clinic, there is a chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office liable.
33
34
I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contract tracing for the interest and safety of the community.
35
36
For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form:
Please sign your signature here
After submitting the form, a link to schedule an appointment with us will appear.
Thank you so much and God bless!
Submit
Should be Empty: