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.