Bahri Dental Group
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/they have a fever or have you/they felt abnormally hot or feverish recently.
(14-21 days)
Have you/they experienced shortness of breath or had trouble breathing?
Do you/they have a dry cough?
Do you/they have a runny nose?
Have you/they recently lost or had a reduction in your sense of smell?
Do you/they have a sore throat?
Have you/they been in contact with someone who has tested positive for
COVID‐19 in the past 30 days?
Have you/they tested positive for COVID‐19 in the past 30 days?
Have you/they been tested for COVID‐19 and are awaiting results?
Have you/they traveled outside the United States by air or cruise ship in
the past 14 days?
Have you/they traveled within the United States by air, bus or train within
the past 14 days?
Have you/they taken Acetaminophen (Tylenol) Ibuprofen (Advil) Naproxen (Aleve) or Aspirin today?
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.