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Covid-19 Patient Disclosure

COVID-19 Patient Disclosure

Patient Disclosure
  • Patient Name * Required
    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 Format: MM slash DD slash YYYY
  • Do you have a new onset fever which appeared within the past 2 weeks? * Required
  • Do you have a new onset of shortness of breath in the past 2 weeks? * Required
  • Do you have a new onset cough in the past 2 weeks? * Required
  • Do you have a sore throat? * Required
  • Have you recently lost or had a reduction of your smell or taste? * Required
  • Have you been in contact with someone who has tested positive for COVID-19? * Required
  • Have you tested positive for COVID-19? * Required
  • Have you been tested for COVID-19 and are awaiting test results? * Required
  • Have you traveled outside of the U.S. in the past 14 days? * Required
  • Have you traveled within the U.S. by air, bus, or train in the past 14 days? * Required
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