Patient Health Disclosure

Please complete the following before coming in for your appointment.


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/trouble breathing? Yes __ No ___

 Do you have a dry cough? Yes ___ No ___ 

Do you have a runny nose?  Yes ___  No ___ 

Have you recently lost or had a reduction in your sense of smell? Yes ___ No ___

Do you have a sore throat?  Yes ___  No ___

 Have you been in contact with someone who has tested positive for COVID‐19?  Yes ___ No ___

Have you tested positive for COVID‐19?  Yes ___  No ___

 Have you been tested for COVID‐19 and are awaiting results?  Yes ___  No ___

 Have you traveled outside the United States by air or cruise ship in the past 14 days?  Yes ___  No ___

Have you traveled within the United States by air, bus or train within the past 14 days?  Yes ___  No ___

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. ____________________________________ ____________________________________