Matic Center for Dental &

TMJ Disorders
COVID-19 Dental Screening Questionnaire & Consent Form
63922-8589218; 044-7953695; 044-3250942 email: maticdental1@gmail.com

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

Figure 1-5 Important Informations from the DEPARTMENT OF HEALTH Ph (DOH)

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 COVID-19 DENTAL TREATMENT CONSENT FORM

C O N F I D E N T I A L

I, ________________________________________________________, of legal age

(First name) (Middle name) (Last name)

(Birth date) ____________________ of my own free will do hereby submit

myself to Dental Treatment during the COVID – 19 PANDEMIC under the
care of
Dr. _______________________________.

( nagbibigay ng permiso at kusang loob na sumailalim sa gamutang pang dental sa

panahon ng pandemya ng COVID-19. )

I understand that the nature of COVID-19 virus has longer incubation period,
during which the carrier of the virus may not show signs and symptoms and
could still be highly contagious. That it is impossible to determine who is
positive and negative, unless testing was done even in asymptomatic patients or
“not a COVID-19 CASE".
(Naiintindihan ko ang COVID-19 virus ay mabilis makahawa at may mahabang
panahon bago lumabas ang mga senyales at sintomas na ang isang tao ay maaring
positibo na, kung kayat, mahirap malaman kung sino ang mayroon at wala, maliban
lamang kung sumailalim na sa pag susuri para sa COVID-19 kahit wala pang mga
senyales at nasa kategorya na “hindi COVID-19 na kaso”.)

I further understand that some dental procedures use water spray, dental
handpiece/ drills, and ultrasonic scalers which generate aerosols which can
cause viruses and bacterias from inside the mouth, through blood and saliva to
spread easily. Aerosols generated can stay in the environment for an indefinite
period of time.

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

( May mga prosesong pang dental na madaling kumalat ang mga bacteria at virus ng
mga makahawang sakit, dahil sa mga paggamit ng tubig at hangin . Ito ay magdudulot
ng lalong pagkalat ng mga patak at wisik ng tubig, dugo o laway na may kasamang
hangin o erosol na galing sa bibig ng pasyente, maaari rin itong magtagal sa paligid.)

Kindly sign in the blank provided after each line below:

(Pirmahan ang patlang sa bawat pagsasaad) :

1. I understand that the risk involves the possibility of becoming exposed to

COVID-A9, due to the frequency of my dental appointment/s, nature of the
virus, and dental procedure/s.
( Nauunawaan ko ang mga risko na makahawa at mahawahan ng COVID-19, base
sa dalas ng pag visita, likas na katangian ng virus at mga proseso ng gamutang
d e n t a l . )
___________________________________________________________________
(Full Name & Signature) (Date signed)

2. I am aware of the World Health Organization (WHO) and Department of

Health Ph. (DOH) Guidelines, that under a Pandemic, all non-urgent
dental care is not recommended. Dental procedures are limited to
emergency cases such as: severe pain, infections, dental trauma, life-
threatening conditions such as fractures of the jaws due to accidents
resulting in: loose teeth, dental implants, crowns and bridges, restorations;
detached or loose fixed orthodontic appliance; orthodontic brackets; wires
and TADS, Occlusal Splints, etc. that may cause asphyxiation, difficulty in
eating or speech or any conditions that cannot wait for 3 months.

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 (Batid ko ang mga panuntunan na ibinahagi ng World Health Organization
(WHO) and Department of Health Ph. (DOH), na ang mga biglaang
pangangailangan lamang katulad ng: masidhing pananakit, impeksyon, trauma sa
ngipin at bibig, panganganib ng buhay dahil sa pagkabali ng mga buto sa panga
sanhi ng aksidente; pagluwag ng ngipin at dental implants; crowns at pasta;
pagkakatanggal o pagluwag ng mga orthodontic appliance, brackets, wires at TADS
at ibapa na maaaring malunok at bumara sa daanan ng paghinga at mga condition
na hindi na maaring ipagliban ng 3 buwan.
______________________________________________________________________
(Full Name & Signature) (Date Signed)

3. I hereby confirm that I am seeking treatment, based on the above criteria.

(Aking kinukumpirma na ako ay nagpapasagawa ng gamutan na nakasaad sa itaas
na pamantayan )

___________________________________________________________________
(Full Name & Signature) (Date Signed)

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 HEALTH DECLARATION

I declare that I have not been a COVID-19 SUSPECT, PROBABLE,

CONFIRMED, IMPROVED or RECOVERED case nor have I been exposed to
people who are either of the above category.

(Kinukumpirma ko na hindi ako COVID-19: SUSPECT, PROBABLE,

CONFIRMED, IMPROVED o RECOVERED na
kaso.____________________________________

I swear that I do not have any of the following signs and symptoms of
COVID-19.
(Kinukumpirma ko na wala akong nararamdaman at nakikitang senyales ng
COVID-19 kagaya ng mga sumusunod) :

• Fever (Lagnat)
• Shortness of breath (Mahirap o kinakapos na paghinga)
• Dry cough (Tuyong ubo o malapot na plema)
• Sore Throat ( Mahapdi at masakit na lalamunan)
• Loss of smell and taste ( Pagkawala ng panlasa at pang-amoy)
• COVID Toes ( May singaw o parang mamaso sa mga daliri ng paa)

(Figure 6) COVID Toes

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 • I do not have any travel history since March 2020.

• I do not have companions/close contact who has travel history under

COVID-19 Classifications A,B,C,_____________(pls refer with photos on
the first page)

• I stayed at home, within the city/ home town/municipality for the period
of the quarantine period from March 12 – May 31, 2020.
______________________________________
• I am aware that non-cooperation or non-disclosure of COVID-19 which is
notifiable disease is punishable by law under RA 11332 with
corresponding penalties.

Full Name & Signature: ______________________________________________

Date Signed: ______________

Signed in the presence of: ________________________________________

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

MATIC DENTAL CLINIC PROTOCOL

1. APPOINTMENTS
STRICTLY, NO WALK- IN.
Please contact our office for appointments:.
Office hours:
Monday - Saturday: 9:00 – 12:00 – 2:00 – 5:00
Landline: (044) 795-3695; 325 0942
Mobile: 63922- 8589218

2. TREATMENT CONSENT & HEALTH DECLARATION

Properly signed consent forms during each appointment sent through email:

3. NO MASK, NO ENTRY POLICY

4. TEMPERATURE & PULSE CHECK
Temperature check for all clinic staff, patients or accompanying guardians at
the door.
Anyone with temperature readings above 37 degrees +++ will not be
allowed to enter the clinic.
Normal range of Pulse:
• Children (ages 6 - 15) 70 – 100 beats per minute
• Adults (age 18 and over) 60 – 100 beats per minute

Use Pulse Oximeter, if no Pulse Oximeter is available:

Count your pulse: _____ beats in 10 seconds x 6 = _____ beats/
minute
Note:
100 beats +++ a minute Tachycardia
Less than 60 beats a minute Bradycardia

5. We ensure safety of the patients. Additional safety and protection

measure or "MODIFIED INFECTION CONTROL" minimal Fee of 500.00
per appointment will be collected.

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 On entry to the clinic:
a. Use foot disinfecting mat and alcohol spray provided at the
reception area. Temperature will be taken before entering.
b. Don the PPE with the help of the clinic assistant.
Sequence for donning: shoe cover, head cap and gown
c. Wait to be called into the operatory.
d. Plastic bag will be provided for your personal belongings. Leave
bag at the designated table inside the treatment room.
e. Using cellphones and other gadgets will not be allowed for the
duration of the treatment.
Prior to exit, at the end of treatment:
a. Make sure to remove PPE with help of clinic assistant.
Sequence for Doffing: head cap, gown and shoe covers
Use alcohol spray or gel after.
b. A plastic bag will be provided for the PPE.
c. For Reusable PPE, follow instructions on how to wash/ sterilize
PPE at home but we discourage using washable PPE.
d. For Disposable PPE, leave with clinic assistant for proper
disposal
e. Use alcohol spray or gel at reception area.
f. Observe proper distancing when paying your bill.
g. Acrylic barrier is placed on the table for additional protection.
h. Confirm next appointment with secretary prior to leaving.

5. BE ON TIME. WE CHARGE NO SHOW FEES.

Please be on time. We can only take fewer patients per day to give time for
sterilization and infection control between patients.
No show Fees at P1, 000.00 / appointment will be charged to cover for cost
of overhead and staff salaries.

6. WAITING
Stay in your car until its your turn.
Our receptionist will text or call when we are ready to accept you to

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD

 Please Observe Social Distancing inside the reception areas.

7. ACCESS TO TREATMENT OPERATORY

ONLY PATIENT is allowed inside the treatment room.
The treatment rooms are fully ISOLATED to Level 3 and 4.
Only ONE Guardian for MINORS can stay inside the reception.
COMPANIONS of an adult patient may stay in their cars or somewhere.
We will video call the guardian BEFORE and AFTER the procedures.
While we enjoy chatting with you, our situation cannot allow such at this
time.

8. PAYMENT OF BILL
We prefer cash-less transactions.
ONLINE Payments are encourage.
Credit Cards will be available.
Personal checks are accepted.
You may pre-arrange assessment and payment of Dental Fees.

9. PRE-APPOINTMENT ORAL HYGIENE.

Patients are required to BRUSH TEETH and gargle with Povidone Iodine
before the appointment.

10. Kindly read the NOTES we posted in the MAIN ENTRANCE.

Thank you so much for your cooperation.

MATIC DENTAL CLINIC

DR. SONIA I. MATIC MSDED; MS NEUROMUSCULAR ORTHODONTICS CRANIOMANDIBULAR ; DMD