This disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 Virus.
Please fill this out 24 hours prior to your service. Filling this out more than 1 day prior to your service will require you to fill out a new form as your health history may change.
It is 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 COVID-19 virus.