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 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.

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.

Do you have a fever or above normal temperature? 
 Yes
 No

Have you experienced shortness of breath or had trouble breathing?
 Yes
 No

Do you have a dry cough?
 Yes
 No

Do you have a runny nose?
 Yes
 No

Have you recently lost or had a reduction in your sense of smell?
 Yes
 No

Do you have a sore throat?
 Yes
 No

Do you have chills?
 Yes
 No

Do you have repeated shaking with chills?
 Yes
 No

Do you have muscle pain?
 Yes
 No

Do you have a headache? 
 Yes
 No

Have you been in contact with someone who has tested positive for COVID‐ 19?
 Yes
 No

Have you tested positive for COVID‐ 19?
 Yes
 No

Have you been tested for COVID‐ 19 and are awaiting results?
 Yes
 No

Have you traveled outside Kansas in the past 14 days?
 Yes
 No

If so, where?
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 health history which may result in a compromised immune system.

Patient Name
Responsible Party
Patient/Responsible Party Signature​

 
Date: