OperaDDS - Form

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES

Patient First Name

Patient Last Name

Patient Date Of Birth

Please immediately review the following form. If any answer is "yes", please contact us immediately.

Please fill out and submit this form the day before your appointment.

Upon submitting, your information will be sent securely back to our office.

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
COVID‐19?

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 in
the past 14 days?

Have you traveled outside Massachusetts within
the past 14 days?

If you answered "YES" to any of the above questions please explain.

*When arriving to the office parking lot, please wait in vehicle.

*Call the office at 413 587-0888, let us know you are here.

*When you get the okay to come in, please wear a mask.

*Companions must wait outside.

*Only personal items that you can carry and keep on yourself are allowed.

*A PPE fee, Code 1999, will be submitted to all insurance companies.

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.

Print Name Of Patient/ Parent or Guardian(if Minor)/Legally Authorized Representative

Relationship If Signed On Behalf Of Patient

Patient/Legally Authorized Representative Signature Click button below to sign. Then click Save Signature. Then click Submit.

Date