Medical Screening

Pre-Visit Patient Screening Form

Please complete this form before Dr. Swetha's home visit. This helps us prepare the safest and most effective treatment plan for you.

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All information shared is strictly confidential and used only to ensure safe dental treatment. This form is not a substitute for professional medical advice.

⚠️ Important Notice: One or more of your answers may require additional precautions before treatment. Dr. Swetha will review this information and contact you to discuss any special preparations needed for your visit.

👤 Patient Information

Patient Name *

Guardian Name *

Date *

✍️ Guardian Signature & Declaration

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that this information will be used solely to ensure safe dental treatment.

Guardian Signature *

Draw your signature above using mouse or finger on touchscreen

After submission, Dr. Swetha will review your form before the visit.
For urgent queries call +91-6303704644

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Form Submitted Successfully!

Thank you. Dr. Swetha will review your screening form and contact you if any additional information is needed before the home visit.

For any questions call +91-6303704644