Screening form prior to dental treatment

Objective: screening for safety standard
Please give exact information by marking in

1. Have you got the history as below;

2. Have you got any symptom as below;

(Please specify the date of recovery………………..)

If you have answers “Yes” on 2. or body temperature above 37.5 °c , clinic has the right to delay dental treatment for you today.


  • Clinic has followed guideline for “Control and Prevention of COVID-19 spreading” advised by The Dental Association of Thailand.
  • If you have COVID-19 infection later, no matter from anywhere, clinic will not be responsible for any such complaints or compensation.
  • The “real” information must be provided by you. If not, you will be fined and/or jailed according to Thai Law.
I hereby confirm that information given above is “true” and I already understand any risk that might be. I sign my name to accept all the condition above.