Covid 19 Infection Declaration

During the potential risk of COVID 19 infection, I have come to ‘Center for Dental Implants & Esthetics’ for dental treatment. Doctor reserves right to TREAT /DEFER /REFER me accordingly. If I happen to be asymptomatic carrier or an un-diagnosed patient with COVID -19 disease, I fully understand it may endanger doctors and other clinic staff. It is my duty and responsibility to take appropriate precautions and follow the protocols suggested by them.

I also know and understand that I may get infection from dental hospital/clinic or from the treating doctor and I will take every precaution to prevent this from happening, at the same I will not hold doctor or staff accountable if such infection occurs to me or person accompanying me.

I hereby agree to be held accountable, regarding the details given by me below.

Please fill in the information to best of your knowledge & belief

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