Patient Screening Form
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.
 
 
Have you experienced any of the following symptoms in the past 48  hours: 

  • fever or chills
  • cough
  • shortness of breath or difficulty breathing
  • fatigue
  • muscle or body aches
  • headache
  • new loss of taste or smell
  • sore throat
  • congestion or runny nose
  • nausea or vomiting
  • diarrhea
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes with:
 
  • Anyone who is known to have laboratory-confirmed COVID-19?
           OR
 
  • Anyone who has any symptoms consistent with COVID-19?
 
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
Are you currently waiting on the results of a COVID-19 test?
 
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.