COVID-19 Screening and Consent
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 Full Name
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First Name
Last Name
Are you fully vaccinated against COVID-19?
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Yes
No
Have you traveled outside Ohio in the past 14 days? (If yes, please contact our office)
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Yes
No
If so, where?
Do you have cough, fever, shortness of breath, or loss of taste or smell?
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Yes
No
Have you recently lost or had a reduction in your sense of smell?
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Yes
No
Do you have a sore throat?
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Yes
No
Do you have chills?
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Yes
No
Do you have repeated shaking with chills?
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Yes
No
Do you have muscle pain?
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Yes
No
Do you have a headache?
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Yes
No
Have you been in contact with someone who has tested positive for COVID‐ 19 in the past 14 days?
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Yes
No
When?
Have you been tested or tested positive for COVID‐ 19 in the past 14 days?
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Yes
No
When?
Have you been tested for COVID‐ 19 and are awaiting results?
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Yes
No
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
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Yes
Person Filling Out This Form
First Name
Last Name
Relationship to Patient
Patient/Parent’s Signature
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Date
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Month
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Day
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Date
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