COVID-19 Patient Disclosure
Parent's Name
Patient(s) Name

This patient disclosure form seeks information from you we must consider before making treatment decisions in the circumstance of COVID-19.

A weak 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 condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand we may ask you to consider rescheduling treatment after discussing any such conditions with us.


In order to reduce the risk of spreading COVID-19, we have asked you a number of screening questions below. For the safety of our team, other patients, and your family, please be truthful and candid in your answers.

Have you, your child(ren) or anyone in the household experienced any of the following signs or symptoms in the past 14 days:

Fever or above normal temperature?
Shortness of breath or trouble breathing?
Dry cough?
Runny nose?
Recent loss or a reduction in their sense of smell?
Sore throat?
Headache, fatigue or GI upset?
In contact with someone who has tested positive for COVIDÔÇÉ19?
Tested positive for COVID-19?
Tested for COVID-19 and are awaiting results?

By signing this document, I acknowledge 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 child's health history which may result in a compromised immune system. Additionally, I knowingly and willingly consent to have dental treatment completed on my child during COVID-19 pandemic.

Parent Signature