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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 to 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 sure conditions with us.


It is also important that you disclose to this office any indication of having seen exposed to COVID-19, or whether you have experienced signs or symptoms associated with the COVID-19 virus.

Do you have a fever or above normal temperature?
Do you have dry cough?
Have you recently lost or had a reduction in your sense of smell?
Have you been in contact with someone who has tested positive for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you experienced shortness of breath or had trouble breathing?
Do you have runny nose?
Do you have sore throat?
Have you tested positive for COVID-19?
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Have you traveled within the United States by air, bus or train within the past 14 days?

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. 

Submission was successful. Thank You.

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