Form

COVID 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.

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 virus.

It is also important that you disclose to this office any indication of having been exposed to COVID, or whether you have experienced any signs or symptoms associated with the COVID virus.

Have you tested positive for COVID in the last 15 days?

Is there anyone living in your home who has tested positive for COVID in the last 30 days?

Are you experiencing any COVID-like symptoms at this time (cough, runny nose, fever, loss of taste or smell)?

If you answered "YES" to any of the above questions, please explain in the box below, and call our office as soon as possible.

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

Relationship If Signed On Behalf Of Patient

*Please come right into the waiting room. No need to call.

*Wearing a mask into our office is at your own discretion.

*Companions must wait outside.

*A PPE fee, Code 1999, will be submitted to all insurance companies, and no additional cost will be incurred to you as the patient.

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

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

Date