Updated 5/18/2020
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.
Yes No
Do you have a fever or above normal temperature?
Have you experienced shortness of breath or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive
for COVID‐19? If yes, what was the date? ___________________
Have you tested positive for COVID‐19? If yes, what date did you test
positive? ____________________________
Have you been tested for COVID‐19 and are awaiting results?
If you have COVID19, how long have you been free of symptoms?
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.
Print Patient Name
Patient Signature (parent if minor)
Provide Date:___________
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