This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstances 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 risks 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 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.
4216 Lincoln Road
Hattiesburg, MS 39402
Mon - Thurs: 8AM - 5PM