Pan Orthodontics : COVID‐19 PANDEMIC ‐ 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 weak 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 virusName* First Last Email* Phone*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 or anyone in your household been tested for COVID-19 coronavirus in the past 14 days?* Yes No If yes, what is the date of the test and what were the results?Have you or anyone in your household had contact with someone who was diagnosed with COVID-19 coronavirus in the past 14 days?* Yes No If yes, what was the date of the test?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. By signing this document, I acknowledge that the answers I have provided above are true and accurateSignature