COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions that may be influenced by the COVID‐19 virus.
 
It is imperitive that you honestly disclose any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.
 
We have immunocompromised patients and we will continue to protect the health of all by holding everyone to the same standards of infection control.
 
***  Be advised that current CDC guidelines do not override this office's in-office mask mandate.  ***
 
***  Please cancel your appointment if you are not willing to wear a mask, even if vaccinated.  ***
Are you vaccinated against COVID-19?


Do you have a fever or above normal temperature?


Have you experienced shortness of breath or had trouble breathing?
 
 
Do you have a dry cough or sore throat?


Have you recently lost or had a reduction in your sense of smell?
 
 
Have you been in contact with someone who has tested positive for
COVID‐19 in the past 14 days?
 
 
Are you currently waiting for COVID‐19 test results?


Have you traveled outside the United States by air or cruise ship in
the past 14 days?
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.