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COVID‐19 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.
* Required

    Do you currently or in the last 14 days have had a fever or temperature over 100.4F? *

    Do you currently or in the last 14 days have you experienced shortness of breath or had trouble breathing? *

    Do you currently or in the last 14 days have you had a dry cough? *

    Do you currently or in the last 14 days have you had a sore throat? *

    In the last 14 days have you been in contact with someone who has tested positive for COVID‐19? *

    In the last 14 days have you tested positive for COVID‐19? *

    In the last 14 days 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 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.