Covid-19 Patient DisclosuresPlease enable JavaScript in your browser to complete this 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.Patient Name *FirstLastPatient Date of Birth *Do you have a fever or above normal temperature? *YesNoHave you experienced shortness of breath or had trouble breathing? *YesNoDo you have a dry cough? *YesNoDo you have a runny nose? *YesNoHave you recently lost or had a reduction in your sense of smell? *YesNoDo you have a sore throat? *YesNoHave you been in contact with someone who has tested positive for COVID‐19? *YesNoHave you tested positive for COVID‐19? *YesNoHave you been tested for COVID‐19 and are awaiting results? *YesNoIf you answered yes to any of the above questions, please provide additional details below:Have you traveled outside of New Jersey in the past 14 days? *YesNoIf you answered yes to the travel question, please enter where you have traveled:Email *Date *Digital Signature *Clear SignatureBy entering your name above you are digitally signing this submission and you acknowledge that the answers you have provided above are true and accurate. You fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to your provider any conditions in my health history which may result in a compromised immune system.Submit