***Please complete this form within 24 hours of your appointment.  If completed too early, you will need to resubmit it again (within 24 hours of 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.
All patients must be wearing a face covering when entering the office.  Only patients will be allowed in the treatment area.
Have you had a fever in the past 21 days?
Do you have shortness of breath or other diffculties breathing?

Do you have a dry cough?
Do you have a runny nose or other flu like symptoms?

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

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 or cruise ship in
the past 21 days?
Have you traveled within the United States by air or cruise ship in
the past 21 days?
If you have traveled more than 100 miles from home, where have you traveled?

The health and safety of our patients and team members remains our top priority and we will continue taking the recommended and appropriate precautions to the best of our ability.  However, it is possible that these precautions will not always block the transmission of viruses or communicable diseases, including but not limited to COVID-19.  Physical distancing may not be possible between patient, dentist, hygienist, dental assistant, office team, and/or sometimes, other patients.  By presenting yourself, child, or family member for dental treatment, you assume and accept the risk of exposure to a communicable disease, including but not limited to COVID-19.   

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.