Form

COVID-19 Pandemic Patient Disclosure (DAY OF)

Please fill out this form THE DAY OF your appoinmtent.

Please be assured our office has always used universal precautions and is current with infection control procedures..

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance any illness, including COVID-19.

Consider delaying treatment if you have risk factors for complications with COVID-19 per the CDC. .

First Name

Last Name

Date Of Birth

Day of screening

Did you read the disclaimer at the top of this form?

Do you have a fever or above normal temperature now or in the past 14-21 days?

Been in contact with someone who has tested positive for COVID-19 in the past 14-21 days?

Are you currently being tested for COVID-19 and are awaiting results?

Have you traveled outside the STATE OR COUNTRY in the past 14 days?

IF YES, PLEASE EXPLAIN:

Patient/Legal Guardian Signature

Date