COVID-19 PATIENT SCREENING AND DISCLOSURE FORM
This patient disclosure form seeks information from you that we must consider before making treatment decision in the circumstance of the COVID-19 virus. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, 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.

PLEASE CLICK HERE TO DOWNLOAD THE COVID-19 PATIENT SCREENING AND DISCLOSURE FORM.