This patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 pandemic.

    A weakened or compromised immune system (which may be due to underlying conditions like cancer, diabetes, asthma, and COPD; treatments like radiation, chemotherapy, and immunosuppressive drugs; and any prior or current disease or medical condition), can put you at greater risk for contracting COVlD-19. Please disclose to us any condition or treatment/medication that weakens or 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 COVID-19.

  • I fully understand and acknowledge the above information, risks and cautions regarding a weakened or compromised immune system and have disclosed to my provider any conditions in my health history which may result in a weakened or compromised immune system.

    By signing this document, I acknowledge that the answers l have provided above are true and accurate.

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