This patient disclosure form seeks information from you that we must consider before making treatment decisions. 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. 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 currently, or in the past 10 days, have/had a fever, cough, shortness of breath, or loss of taste or smell?
Are you, or anyone you have had close contact with in the last 10 days, diagnosed with or suspected to have COVID-19?

Are you currently under quarantine order and/or are you awaiting a COVID-19 test result?
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.