Dentawell Dental Care - Patients Information
For the health and safety of our community, declaration of personal details and illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.

NOTE: The data collected is required in order that we can ensure the health and well-being of our community, allowing us to contact and trace visitors in case of a Covid-19 outbreak. The data collected will be processed by Dentawell Dental Care in its current format and will not be passed on to third parties unless required legally to do so. The data will be held securely by Dentawell Dental Care.

For any queries or concerns you can contact us on any of the following options.

Website:     https://www.dentawell.co.in/
Email:         dentawellcare@gmail.com
WhatsApp: 8281802884
Phone:        8281802821
Doctor:        6366632233
Office:         9538475214
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Date
MM
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DD
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Time
Time
:
Clinic Location *
Please select the Location of clinic
Name *
Age *
Gender *
Current Address *
Permanent Address *
Contact Number *
WhatsApp Number
Email
Reason for Visit *
Have you now, or in the past 48 hours, had any of the following flu-like symptoms? *
Required
Have you or any immediate family members been to any of the covid19 affected areas? *
Please mention your travel history in last 14 days, if any
Have you or any immediate family members come into close contact with a confirmedcase of Coronavirus in the last 14 days? (“Close contact” means being at a distance of lessthan three feet for more than 15 minutes.) *
If yes, Name of City/Country where contact took place and other details
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