Form

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.

Do you have or have you experienced any of the following: shortness of breath or had trouble breathing, fever or above normal temperature, dry cough, runny nose or sore throat?

Have you recently lost or had a reduction in your sense of smell?

Have you been tested or have you been in contact with someone who has tested positive for COVID‐19 in the past 14 days?

Have you traveled within or outside the United States by air, bus, train or cruise ship in the past 14 days?

I consent to have my doctor and staff perform medical procedures, whether regarded as necessary, elective or aesthetic, during the time of the COVID-19 pandemic and after. I understand having my procedure performed at this time, despite my own efforts and those of my Doctor, may increase the risk of my exposure to COVID-19.

I have informed my Doctor of any COVID-19 testing I or any person living with me during the past 14 days has received, as well as the results of that testing, and if I am tested between now and the date of my procedure I will immediately provide results of that test to my Doctor.

I confirm neither I nor any individual living with me has any of the COVID-19 symptoms, listed by the center for Disease Control during the past 14 days has experienced any such symptoms; and that I and all persons living me for the past 14 days have practiced all personal hygiene, social distancing and other COVID-19 recommendations.

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.

First

Last

Signature

Date