Have you ever experienced any of the following in the past 21 days? - Fever, chills, loss of flavor, cough, sore throat, difficulty in breathing, shortness of breath and chest tightness.

COVID-19 Pandemic Preparedness Consent, 2021. My understanding is that COVID-19 is a result of the novel coronavirus. I understand that the virus has a long incubation period during which the virus carriers can show no symptoms and remain contagious. I understand that I may be a subclinical or asymptomatic carrier or an undiagnosed patient with COVID-19 and put doctors and clinic staff at risk. I understand that the clinic has taken all appropriate safety measures to protect and prevent transmission of the virus within the clinic and I agree to follow the prescribed protocols. I understand that I may be at risk of contracting the novel coronavirus, considering the nature of the virus and not hold doctors and clinic staff accountable, if such infection occurred to me or my accompanying person. I agree to consult my family physician prior to the clinic visit, if any of the following medical conditions apply - diabetes, cardiovascular disease, hypertension, lung disease, moderate to severe asthma and active malignancy. I understand that the Ministry of Health and Family Welfare has asked people to keep a physical distance of at least six feet and you can't keep that distance and get dental care.