Updated 2/24/2021
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
1. Have you been fully vaccinated for COVID19?
If someone is fully vaccinated, they have received both doses of
OVID-19 vaccine, and it has been 14 days since their second dose.)
YES, skip to question 12. You do not need to answer questions 2
2. Do you have a fever or above normal temperature?
3. Have you experienced shortness of breath or had trouble breathing?
4. Do you have a dry cough?
5. Do you have a runny nose?
6. Have you recently lost or had a reduction in your sense of smell?
7. Do you have a sore throat?
8. Have you been in contact with someone who has tested positive for
COVID‐19? If yes, what was the date? __________________
9. Have you tested positive for COVID‐19? If yes, what date did you test
positive? ____________________________
10. Have you been tested for COVID‐19 and are awaiting results?
11. If you have COVID19, how long have you been free of symptoms?
12. 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.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
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Patient Signature (parent if minor)
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