Little Silver Mammography & HerSpace | 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.

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 *

First

Last

Patient Date of Birth *

Do you have a fever or above normal temperature? *

Yes
No

Have you experienced shortness of breath or had trouble breathing? *

Yes
No

Do you have a dry cough? *

Yes
No

Do you have a runny nose? *

Yes
No

Have you recently lost or had a reduction in your sense of smell? *

Yes
No

Do you have a sore throat? *

Yes
No

Have you been in contact with someone who has tested positive for COVID‐19? *

Yes
No

Have you tested positive for COVID‐19? *

Yes
No

Have you been tested for COVID‐19 and are awaiting results? *

Yes
No

If 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? *

Yes
No

If you answered yes to the travel question, please enter where you have traveled:

Email *

Date *

Digital Signature *

By 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.