COVID-19 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 virus.
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.
