Skip to content
Facebook
Instagram
X
LinkedIn
Skype
Clinic No.: +91 8459647556
|
Contact Dr. Priyank: +91 9970192595
|
drpriyank@smilekraftdentistry.com
Search for:
Home
Our System
Smilekrafters
Ambience
Our Forte
Restorative Dentistry
Dental Implants
Dental Bridges
Removable Dentures
Dental Crowns
Dental Fillings
Post & Core Treatment
Full Mouth Rehabilitation
Cosmetic Dentistry
Porcelain Veneers
Ceramic Caps
Composite Bonding
Teeth Whitening
Gum Contouring & Depigmentation
Orthodontics
Dental Emergencies
Teeth Sensitivity & Toothache
Root Canal Treatment
Preventive Treatments
Teeth Cleaning
Cavity Prevention
Bite Guard
Laser Assisted Dentistry
Oral Surgeries
Tooth Removal
Periodontal Surgeries
Bone Grafting
Computer Guided Surgeries
Why Choose Us
Our Work
Our Star Results
Patient Experiences
For International Visitors
Caring for Life
Privacy policy
Infrastructure & Technology
Safety & Quality Assurance
Fees & Cost Analysis
SmileSpeak
Something New, Something Exciting
Contact Us
Search for:
Home
Our System
Smilekrafters
Ambience
Our Forte
Restorative Dentistry
Dental Implants
Dental Bridges
Removable Dentures
Dental Crowns
Dental Fillings
Post & Core Treatment
Full Mouth Rehabilitation
Cosmetic Dentistry
Porcelain Veneers
Ceramic Caps
Composite Bonding
Teeth Whitening
Gum Contouring & Depigmentation
Orthodontics
Dental Emergencies
Teeth Sensitivity & Toothache
Root Canal Treatment
Preventive Treatments
Teeth Cleaning
Cavity Prevention
Bite Guard
Laser Assisted Dentistry
Oral Surgeries
Tooth Removal
Periodontal Surgeries
Bone Grafting
Computer Guided Surgeries
Why Choose Us
Our Work
Our Star Results
Patient Experiences
For International Visitors
Caring for Life
Privacy policy
Infrastructure & Technology
Safety & Quality Assurance
Fees & Cost Analysis
SmileSpeak
Something New, Something Exciting
Contact Us
Home
Our System
Smilekrafters
Ambience
Our Forte
Restorative Dentistry
Dental Implants
Dental Bridges
Removable Dentures
Dental Crowns
Dental Fillings
Post & Core Treatment
Full Mouth Rehabilitation
Cosmetic Dentistry
Porcelain Veneers
Ceramic Caps
Composite Bonding
Teeth Whitening
Gum Contouring & Depigmentation
Orthodontics
Dental Emergencies
Teeth Sensitivity & Toothache
Root Canal Treatment
Preventive Treatments
Teeth Cleaning
Cavity Prevention
Bite Guard
Laser Assisted Dentistry
Oral Surgeries
Tooth Removal
Periodontal Surgeries
Bone Grafting
Computer Guided Surgeries
Why Choose Us
Our Work
Our Star Results
Patient Experiences
For International Visitors
Caring for Life
Privacy policy
Infrastructure & Technology
Safety & Quality Assurance
Fees & Cost Analysis
SmileSpeak
Something New, Something Exciting
Contact Us
Screening/Disclosure form during Covid19 Epidemic
Screening/Disclosure form during Covid19 Epidemic
Dr. Priyank Mathur
2020-08-26T00:27:24+05:30
Please enable JavaScript in your browser to complete this form.
Full Name
*
Age
*
Sex
*
Mobile Number
*
Email
*
Residential Address
*
Did you have any symptoms of Fever, Cough, Sore throat and/or fatigue anytime during last 21 days?
*
Yes
No
If yes and possible, please explain the symptom and its intensity.
Did you experience any difficulty in breathing anytime during last 21 days?
*
Yes
No
Did you have any exposure to a known or suspected case of Covid19 patient in last 21 days?
*
Yes
No
Maybe
Are you residing in a locality that has been notified by the Govt. as a covid containment zone in last 21 days?
*
Yes
No
Have you visited any other medical facility/hospital in last 21 days?
*
Yes
No
If yes, please mention the reason
Have you ever been tested for Covid19?
*
Yes
No
If yes, please mention positive or negative
Compulsory Checkbox
*
The above information given by me is true to the best of my knowledge. I fully understand and acknowledge that withholding or mis-representation of any information is highly unethical and against the interest of larger population during this pandemic.
Compulsory Checkbox
*
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 Smilekraft Dentistry or any of its staff responsible for it. I hereby knowingly and willingly give consent to have my emergency/urgent dental treatment completed during the Covid pandemic.
Website
Submit
Toggle Sliding Bar Area
PRIVACY POLICY
SAFETY PROCESSES
COVID 19 Disclosure & Consent
form
EASY PAYMENT
For International Transactions please Paypal at:
paypal.me/PriyankMathur
Page load link
Go to Top
