COVID 19 Patient Disclosure Form

1

Patient Name* This field is required.

First Name

Last Name

2

This patient disclosure form seeks information from you that we must consider before making treatmentdecisions in the circumstance of the COVID‐19 virus.

A weakened 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.

3

Do you have a fever or above normal temperature?* This field is required.

YESNO

4

Have you experienced shortness of breath or had trouble breathing?* This field is required.

YESNO

5

Do you have a dry cough?* This field is required.

YESNO

6

Do you have a runny nose?* This field is required.

YESNO

7

Have you recently lost or had a reduction in your sense of smell?* This field is required.

YESNO

8

Do you have a sore throat?* This field is required.

YESNO

9

Have you been in contact with someone who has tested positive for COVID‐19?* This field is required.

YESNO

10

Have you tested positive for COVID‐19?* This field is required.

YESNO

11

Have you been tested for COVID‐19 and are awaiting results?* This field is required.

YESNO

12

Have you traveled outside of the US in the past 14 days?* This field is required.

YESNO

13

Where did you travel?* This field is required.

14

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.

15

Date* This field is required.

Date

16

Signature* This field is required.

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