Screening Disclosure Form For Patients Name(Required)Phone(Required)Email(Required) Gender(Required)Please Select Your GenderMaleFemaleAge(Required)Please enter a number from 1 to 100.Clinic Location(Required)Please Select Your Preferred LocationSpHear Clinic DelhiSpHear Clinic NoidaSpHear Clinic PatnaAppointment Date(Required) MM slash DD slash YYYY Do you have any symptoms of Fever, Cough, Sore throat, Fatigue, Sudden loss of smell/taste anytime during last 21 days ? *(Required) Yes No Did you experience any difficulty in breathing anytime during last 21 days ? *(Required) Yes No Do you have any exposure to a known or suspected case of Covid-19 patient in last 21 days ? *(Required) Yes No Have you visited any other medical facility /hospital in last 21 days ? If yes, for what reason ? *(Required) Yes No Are you residing in a locality that has been notified by the government as a covid containment zone ? *(Required) Yes No Have you ever been tested for Covid-19 ?If yes, give details *(Required) Yes No Agree(Required)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. I understand the Covid-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I fully understand and acknowledge that I / my patient may be an asymptomatic carrier of the disease / undiagnosed patient with COVID19. I confirm that it is my / my patient’s responsibility to take appropriate precautions and strictly comply with all safety precautions and protocols advised as not doing so may endanger doctors and clinic staff. I also understand that, due to the contagious nature of the disease, the fact that I could have been in the incubation period and not be aware, and/or characteristics of procedures and being at a clinic despite best disinfection protocols applied, I / my patient could develop an infection later. In the eventuality of my testing covid positive at a later date, I will not hold the clinic/staff / management responsible for it. I hereby knowingly and willingly give consent to have my investigations and treatment completed during the Covid pandemic. Accept Above Information(Required)CAPTCHA
