Due to COVID-19 pandemic we are strictly by appointment only until further notice. We can accommodate 4 to 5 patients only per branch per day. Please answer the questionnaire. Print, sign and bring it on the date of your appointment. This will serve also as proof of appointment. We will confirm your appointment via email or call 2 to 3 days before your appointment date. Please take note of the following: Wearing face mask is a requirement Companion is not allowed inside the clinic and treatment room except for minor We encourage you to make the clinic as your first destination for the day Wearing shoes with lace is not recommended when you come to the clinic We encourage cashless transaction through credit card and PayPal Patient is encourage to bring one bag only and wear minimal jewelry This questionnaire is designed with your safety in mind and must be answered honestly. Your answers will be reviewed prior to your appointment and a member of our team will contact you if we recommend rescheduling to a later date. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions. Thank you for your consideration and understanding. Note: HMO (Health Maintenance Organization) cards not accepted. First Name * Last Name * Contact Number * Email * Clinic to Visit * SM Mall of Asia (Mon-Sun, 10AM-6PM) St. Luke's Medical Center - QC (Mon, Wed, Fri, 10AM-4PM) SM City North EDSA (Mon-Sat, 10AM-5:30PM) Centuria Medical Makati (Mon-Sat, 10AM-5:30PM) Preferred Date & Time of Visit Date of Visit * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year202320242025 Year Time of Visit * 10:30 AM 11:30 AM 1:00 PM 3:00 PM 5:00 PM Your Concerns * Consultation Crown Cleaning Bridge Filling Complete Denture Sealant Removable Denture Root Canal Treatment Veneers / Laminates Orthodontic Treatment Teeth Whitening Invisalign Cosmetic Gum Surgery - Gum Recontouring Periodontal Therapy Oral Surgery (Laser) Gum Bleaching Pediatric Dentistry / Pedodontics Gum Grafting Implant Fluoride Application Bone Grafting TMJ Therapy Sinus Lifting X-ray Smile Makeover Complete Ortho Package CBCT Scan Subscribe to newsletter Health Declaration Do you have a fever or above normal temperature? * Yes No Have you experienced shortness of breathe or had trouble breathing? * Yes No Do you have a dry cough? * Yes No Do you have runny nose? * Yes No Have you recently lost or had a reduction in your sense of smell? * Yes No Do you have sore throat? * Yes No Do you have diarrhea? * Yes No Have you been in contact with someone who has tested positive for COVID-19? * Yes No Have you been tested for COVID-19? * Yes No Have you been tested for COVID-19 and are awaiting results? * Yes No Have you traveled outside the Philippines by air or cruise ship in the past 14 days? * Yes No Have you traveled within the Philippines by air, bus, or train within the past 14 days? * Yes No Do you have diabetes? * Yes No If so, do you have to take insulin injections? * Yes No Do you have asthma or COPD? * Yes No Submit
