COVID-19 Pandemic - Patient Disclosures

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.

Patient Name

Phone Number

Do you have a fever or above normal temperature?

Yes

Have you experienced shortness of breath or had trouble breathing?

Yes

Do you have a dry cough?

Yes

Do you have a runny nose?

Yes

Have you recently lost or had a reduction in your sense of smell?

Yes

Do you have a sore throat?

Yes

Have you been in contact with someone who has tested positive for COVID‐19?

Yes

Have you tested positive for COVID-19?

Yes

Have you been tested for COVID‐19 and are awaiting results?

Yes

Have you traveled outside the United States by air or cruise ship in the past 14 days?

Yes

Have you traveled within the United States by air, bus or train within the past 14 days?

Yes

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.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself or the entity I am authorized to represent.