COVID-19 Patient Disclosure Form

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? *
YesNo
Have you experienced shortness of breath or had trouble breathing? *
YesNo
Do you have a dry cough? *
YesNo
Do you have a runny nose? *
YesNo
Have you recently lost or had a reduction in your sense of smell? *
YesNo
Do you have a sore throat? *
YesNo
Do you have chills? *
YesNo
Do you have repeated shaking with chills? *
YesNo
Do you have muscle pain? *
YesNo
Do you have a headache? *
YesNo
Have you been in contact with someone who has tested positive for COVID‐19?
YesNoPrefer Not to Answer
Have you tested positive for COVID‐19?
YesNoPrefer Not to Answer
Have you been tested for COVID‐19 and are awaiting results?
YesNoPrefer Not to Answer
Have you traveled outside Nebraska in the past 14 days?
YesNoPrefer Not to Answer
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.

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

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