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COVID-19 PANDEMIC PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19, also known as “Coronavirus,” pandemic.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, 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 such disclosures may impact treatment decisions.

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness.

These symptoms may appear 2-14 days after exposure to the virus. It is important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

1. Have you been in contact with someone who has tested positive for COVID-19 within the last 14 days?

2. Have you tested positive for COVID-19 within the last 14 days?

3. Have you been tested for COVID-19 and are awaiting results?

4. Do you have a fever or above normal temperature?

5. Have you experienced shortness of breath or had trouble breathing?

6. Do you have a cough or running nose or sore throat?

7. Have you recently lost or had a reduction in your sense of smell or taste?

8.Have you experienced chills or repeated shaking with chills within the last 14 days?

9. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

10. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

11. Do you otherwise feel unwell?

I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history. By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Patient's full name *:

Date: 12/22/2024


        



1st Care Dental
29110 Highway 290 Suite 200
Cypress, TX 77433
(281) 256-7331
Office Hours:
Monday:  9am-6pm
Tuesday: 9am-6pm
Wednesday: 9am-6pm
Thursday: 9am-6pm
Friday:  9am-6pm
Saturday: 9am-2pm

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