Patient Visitor Disclosure Form Office Location*Select an OfficeAhwatukee (Ray Rd/101)Central Phoenix (Central/Camelback)Paradise Valley (Scottsdale Rd/Shea Blvd)Pinnacle Peak (Pinnacle Peak/Scottsdale RdGilbert (San Tan Village Mall)Full Name* Phone*Email* This patient disclosure form seeks information that must taken into consideration prior to determining treatment needs amidst the COVID-19 pandemic. Individuals with weak or compromised immune systems are at greatest risk for contracting COVID-19. This includes patients with conditions such as, but not limited to, diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current medical condition. We ask that you disclose any condition that may compromise your immune system. Please be advised that treatment may be rescheduled in the interest of the health and safety of our patients and team. If you have been exposed to COVID-19 or are experiencing any signs or symptoms associated with the virus, it is essential that you share this information with an AZPerio team member prior to receiving treatment.Do you have a fever or above normal (97°F-99°F) temperature?* Yes No Have you experienced trouble breathing or shortness of breath?* Yes No Do you have a dry cough?* Yes No Do you have a sore throat?* Yes No Are you experiencing any cold or flu like symptoms (body aches, chills, etc.)?* Yes No Have you or someone in your household traveled outside the United States in the past 14 days?* Yes No Have you or someone in your household been in close contact with a COVID-19 patient(s) or COVID-19 exposed patient(s)?* Yes No Have you been exposed to someone who tested positive for COVID-19 or exhibited symptoms in the 14 days before you got sick?* Yes No Have you been tested for COVID-19?* Yes No If yes, were the results?* Positive Negative Awaiting Results What, if any, concerns do you have for your immediate family and household with regard to their risk for COVID-19, by your choice to visit our practice?What, if any, restrictions are you under by your physician with respect to your household member(s) condition(s)?By submitting this document, you acknowledge that you fully understand the above information and have disclosed to AZPerio any medical conditions, symptoms, or recent travel that may be attributed to a compromised immune system or increased level of exposure.
