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Home COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES FORM

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES 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.

Do you have a fever or above normal temperature?

YES NO

Have you experienced shortness of breath or had trouble breathing?

YES NO

Do you have a dry cough?

YES NO

Do you have a runny nose?

YES NO

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