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 have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for

Have you tested positive for COVID‐19?

Have you been tested for COVID‐19 and are awaiting results?

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

Have you traveled within the United States by air, bus or train within
the past 14 days?

Have you ever been diagnosed with COVID-19?

If you have been diagnosed with COVID-19, what were your symptoms?

Were you hospitalized with COVID-19?

If you were hospitalized with COVID-19, when were you Tested/Cleared?
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.

As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "coronavirus," at any time or in any place. Be assured that we continue to follow state and federal regulations as well as recommended universal personal protective equipment (PPE) and disinfection protocols to limit transmission of all diseases in our office.

Despite our careful attention to sterilization, disinfection and the use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be exposed at your gym, grocery store or favorite restaurant. Nationwide social distancing has reduced the transmission of the coronavirus. Although we have taken measures to enable social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dental healthcare team members and sometimes other patients at all times.

By signing this document, I acknowledge that the answers I have provided above are true and accurate. Additionally, although exposure is unlikely, I accept the risks and consent to treatment.