OperaDDS - Form

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES

Patient First Name

Patient Last Name

Patient Date of Birth

This patient and household disclosure form seeks information from you about the patient and members of the patient's household 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 or any member of the patient's household having been exposed to COVID‐19, or whether the patient or any member of the patient's household has experienced any signs or symptoms associated with the COVID‐19 virus.

Does the patient or any member of the patient's household have a fever or has felt hot or feverish recently (14-21 days)?

Has the patient or any member of the patient's household experienced shortness of breath or had trouble breathing?

Does the patient or any member of the patient's household have a cough?

Does the patient or any member of the patient's household have any other flu-like symptoms, such as chills, muscle pain, headache, sore throat, fatigue, or runny nose?

Has the patient or any member of the patient's household recently lost or had a reduction in sense of smell or taste?

Does the patient or any member of the patient's household have any gastrointestinal symptoms, such as a stomach upset, nausea, vomiting or diarrhea?

Has the patient or any member of the patient's household been in contact with someone who has tested positive for COVID‐19?

When?

Has the patient been tested for COVID‐19?

When was the patient most recently tested for COVID-19?

Were the most recent COVID-19 test results positive?

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.

I am the patient's:

Parent First Name

Parent Last Name

Legal Guardian First Name

Legal Guardian Last Name

Patient First Name

Patient Last Name

Parent Signature

Legal Guardian Signature

Patient Signature

Date