Watching For COVID-19 -----
We Take Every Precaution To Provide Care Safely Amidst the Coronavirus
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 weakened or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD,
cancer treatment, radiation, chemotherapy, and any prior 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 your office visit or 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.