This patient disclosure form seeks information from you about the patient that we must consider before making treatment decisions in the circumstance of the COVID‐19 pandemic.
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 the patient at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises the patient's 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 the patient having been exposed to COVID‐19, or whether the patient has experienced any signs or symptoms associated with the COVID‐19 virus.
Does the patient have a fever or has felt hot or feverish recently (14-21 days)?
Has the patient experienced shortness of breath or had trouble breathing?
Does the patient have a cough?
Does the patient have any other flu-like symptoms, such as chills, muscle pain, headache, sore throat, or fatigue?
Has the patient recently lost or had a reduction in sense of smell or taste?
Does the patient have any gastrointestinal symptoms, such as a stomach upset, nausea, vomiting or diarrhea?
Has the patient been in contact with someone who has tested positive for COVID‐19?
Has the patient been tested for COVID‐19?


I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.