VIRTUAL CHECK-IN/COVID‐19 - PATIENT DISCLOSURES
PLEASE DO NOT FILL OUT THIS FORM UNTIL YOU ARE IN OUR PARKING LOT!
 
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.
 
As per the New Jersey Division of Consumer Affairs, wearing a mask is OPTIONAL in medical/dental offices by all who are entering.
1. Are you experiencing shortness of breath, trouble breathing cough, runny nose, sore throat, or fever?
 
 
2. Have you been tested for COVID‐19 and are awaiting results?
 
 
 
 
In our efforts to continue to offer the safest environment for our patients and team, we are happy to continue to call you after the visit to provide updates on treatment.

However, we welcome any parent/guardian who wants to accompany their child into the building.
Please let us know if you will be accompanying your child into the building.  Questions 1 and 2 apply to parent/guardian as well.
Please submit form and wait in your car and we will call you when ready.