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Patient Visitor Disclosure Form

Office Location*
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.

Widely lauded for expertise, professionalism and sincere patient compassion, AZPerio is home to some of the state’s leading board-certified periodontists, each possessing a unique combination of clinical training and experience.

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