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COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk
for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.

Have you been fully vaccinated for COVID-19 (both 1st and 2nd doses)?

If yes, when was the 2nd dose administered:

If the answer for above question is YES, please disregard the rest of this form, SIGN and click SUBMIT.

Do you have any of these symptoms: fever, dry cough, runny nose, shortness of breath, sore throat, lost/reduction in your sense of smell?

Have you been in contact with someone who has COVID‐19 within the last two weeks?

Have you tested positive for COVID‐19?

If yes, when:

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

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