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Meet the Team
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Online Patient Forms
Privacy Policy
About
About Us
Hancock Location
Contact
Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
My Account
Frequently Asked Questions
Online Patient Forms
Privacy Policy
About
About Us
Hancock Location
Contact
Call for appiontment
Call For Appointment
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Covid-19 Patient Disclosure
COVID-19 Patient Disclosure
Patient Disclosure
Patient Name
*
Required
First
Last
The patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstances of the COVID-19 virus. A weak or compromised immune system ( including, but not limited to, conditions like diabetes, asthma, autoimmune disorders, 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.
Date
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Do you have a new onset fever which appeared within the past 2 weeks?
*
Required
Yes
No
Do you have a new onset of shortness of breath in the past 2 weeks?
*
Required
Yes
No
Do you have a new onset cough in the past 2 weeks?
*
Required
Yes
No
Do you have a sore throat?
*
Required
Yes
No
Have you recently lost or had a reduction of your smell or taste?
*
Required
Yes
No
Have you been in contact with someone who has tested positive for COVID-19?
*
Required
Yes
No
Have you tested positive for COVID-19?
*
Required
Yes
No
Have you been tested for COVID-19 and are awaiting test results?
*
Required
Yes
No
Have you traveled outside of the U.S. in the past 14 days?
*
Required
Yes
No
Have you traveled within the U.S. by air, bus, or train in the past 14 days?
*
Required
Yes
No
Consent
*
Required
I acklowledge that the answers I have provided above are true and accurate.
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.
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