SMILE KOLKATA DENTAL CLINIC APPOINTMENT REQUEST FORM
Dear Patient ,

Kindly fill the form accurately for requesting a dental appointment for the patient. We will contact you via WhatsApp ( 87776-12548 ) within 4 hours of receipt of this form. Please make sure all details are correctly and carefully filled. Please ensure the following while visiting the clinic -

1) Wear a Proper Mask

2) Bring Minimal Items inside the Clinic

3) Please Remove your Shoes prior to Entering the Clinic

4) Please Wait outside the Clinic and let the Staff Guide you for Sanitizing your Hands & Feet

5) Maintain Social Distancing while in the Clinic

6) Patient Accomplice will not be allowed to Enter the Clinic Area unless Deemed Necessary

7) All Fixed Appointments will be confirmed only after Verification of given Mobile Number from our End.

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KINDLY ENTER YOUR NAME
KINDLY ENTER YOUR AGE
KINDLY ENTER YOUR SHORT ADDRESS
KINDLY ENTER YOUR WHATSAPP MOBILE NUMBER ?
DUE TO COVID 19 PANDEMIC , DO YOU WANT PHYSICAL CONSULTATION OR ONLINE VIDEO CONSULTATION FOR YOUR EMERGENCY DENTAL PROBLEM  ?
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COVID 19 DECLARATION A :       ARE YOU SUFFERING FROM FEVER OR COUGH OR BREATHING DIFFICULTY SINCE THE LAST 15 DAYS ?
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COVID 19 DECLARATION B  :     HAVE ANY OF YOUR FAMILY MEMBERS OR CLOSE CONTACTS BEEN DIAGNOSED WITH CORONAVIRUS DISEASE ?
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COVID 19 DECLARATION C :      HAVE YOU BEEN PUT ON HOME QUARANTINE BY LOCAL AUTHORITIES DUE TO HIGH RISK OF CORONAVIRUS DISEASE ?
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PLEASE TICK THE GROSS DIAGNOSED MEDICAL CONDITIONS YOU KNOW YOU HAVE ? THE DETAILS WOULD BE TAKEN BY THE DOCTOR DURING THE CONSULTATION.
IF POSSIBLE , PLEASE LIST DOWN THE MEDICATIONS YOU TAKE DAILY ? IN ADDITION YOU MAY SEND IMAGE OF THE LAST PRECRIPTION OF YOUR PHYSICIAN
PLEASE TICK IF ANY OF THE BELOW IS APPLICABLE TO YOU ?
WHAT IS YOUR MAIN DENTAL PROBLEM CURRENTLY ?
PLEASE MENTION THE DATE & TIME YOU PREFERRED FOR CONSULTATION ?                                                                          Please Note : It is an Evening Clinic. The alloted date and time will be discussed with you via WhatsApp after submission of this request form.  
DUE TO THE COVID 19 PANDEMIC , I WILL COOPERATE WITH THE DOCTORS FOR MAINTAINING SOCIAL DISTANCING  AND ALL NECESSARY PRECAUTIONS FOR PREVENTING CORONAVIRUS DISEASE
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