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 infection control procedures. ***