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?

 

 

Any other flu-like symptoms, such as gstrointestinal upset, headache or fatigue?

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?

 

 

Have you/they traveled 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. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.