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Covid 19 Pandamic patient Disclosures

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Covid 19 Pandemic Patient Disclosures( * mandatory to fill )

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 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.

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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 systems.

By Signing this document, I acknowledge that the answers I have provided above are true and accurate.

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