Form

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 infection control procedures. ***

Do you have a fever or above normal temperature?

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?

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.

First

Last

Signature

Date