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COVID-19 PATIENT DISCLOSURE
Patient Name:____________________________________ Date:______________
A weakened 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 conditions- can put you at greater risk for contracting COVID-19. Please disclose any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such condition with us.
ARE YOU OVER THE AGE OF 60? (CIRCLE ONE): YES NO
Do you have or have you experienced any of the following conditions within the last 14 -21 days?
Please circle any which apply:
• Fever or have you felt feverish? Yes No
• Shortness of breath or other breathing difficulties? Yes No
• Cough or a sore throat? Yes No
• Any flu like symptoms, such as fatigue, headaches, or body ache? Yes No
• Any gastro-intestinal symptoms such as nausea or diarrhea? Yes No
• Loss of taste or smell? Yes No
Do you have heart, lung, or kidney disease, diabetes or any autoimmune disorders? Yes No
Are you / or have you been in contact with any confirmed COVID-19 positive patients? Yes No
Have you traveled internationally to any COVID-19 affected country in the past 2 weeks? Yes No
Have you tested positive for COVID-19 or are you awaiting results? Yes No
I fully understand and acknowledge the above information, risks, and cautions 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.
Signature_____________________________________ Date____________________
You are receiving dental care during the events of a COVID-19 National Emergency. Please be advised that there may be risks in being in the proximity of dentists, patients, or staff. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission.
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