PLEASE IMMEDIATLY REVIEW THE FOLLOWING FORM. If any answer is "yes", please contact us immediately.
PLEASE COMPLETE AND SUBMIT THIS FORM WITHIN 48 HOURS PRIOR TO YOUR APPOINTMENT. Upon submitting, your information will be sent securely back to our office.
PLEASE CONTACT OUR OFFICE IF YOU TEST POSITIVE FOR COVID WITHIN 3 DAYS AFTER YOUR APPOINTMENT.
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.