COVID-19 Questionnaire


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, any prior or current disease or medical condition), can put you at higher 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.

Please complete the form below and click "Submit Form".
All fields are required.