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 a fever or chills?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have congestion or a runny nose?

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

Do you have a sore throat?

Do you have diarrhea, nausea or vomiting?

Have you been in contact with someone who has tested positive for COVID-19?

Have you/someone in your family tested positive for COVID-19 in the past 14 days or have you/someone in your family been tested for COVID‐19 and are awaiting results?

Have you traveled out of the United States and returned within the past 7 days?

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.

Patient First Name

Patient Last Name

Parent/ Patient Signature

Date