Anamnesis Form

Dear patient, the following data will be collected strictly confidential and will not be disclosed to third parties. Are you or have ever been affected by one of the following diseases (select the diseases that you have suffered or still suffer from, specifying the details below). Have you ever had allergic reactions following treatment with antibiotics and / or penicillin, anesthetics, anti-inflammatories? Are you allergic to any medications?

ANAMNESIS FORM

ANAMNESIS QUESTIONNAIRE AND INFORMED CONSENT Dental Care During the COVID 19 emergency

I declare

To have been informed in a clear and understandable way by the ‘’Travel and Smile’’ clinic of the potential risks during the activity follow-up to the COVID 19 emergency.

The potential clinical implications in case of postponement or refusal of the intervention treatment as well as the reasons for that have been clarified indicate to do it at this time.

Following the COVID emergency since the infection is now widespread in the population, often with few or no symptoms, I was adequately informed about the risk of contracting a COVID infection while in the clinic, even if all the appropriate measures to avoid it are taken.

The most common symptoms of COVID 19 are:

Fever, Dry cough, Asthenia, Dyspnea, Pharyngodynia, Headache, Diarrhea

THE PATIENT UNDERTAKES TO NOTIFY ANY CHANGES IN HIS HEALTH OR IN THE MEDICINES THAT THEY ARE TAKING

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