Wellness Form

COVID-19 Wellness Form
Please complete the form prior to your appointment. We ask that you complete the form 12-24 hours prior to your appointment. Should there is any change in your medical condition after you submit the form, you are obligated to inform us as soon as possible so we can reschedule your appointment accordingly.

Upon your arrival, we will take and record your body temperature and confirm your wellness status.

Please wear a mask to your appointment. The building still requires a mask for everyone who is entering the building.
Date of your appointment

MonthDayYear
Date
Name

First NameLast Name
Name of your general dentist
Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

YesNo
Within the past 14 days, have you had close contact with anyone that you know had COVID-19 or COVID-like symptoms? A close contact is defined as being 6 feet (2 meters) or closer for more than 15 minutes total in a 24-hour period.

YesNo
Have you had any one or more of these symptoms today or within the past 24 hours? Please indicate any symptoms that are not attributted to existing conditions (e.g., allergies)

Yes
CoughShortness of breathUnexplained fever(≥100º F)Chills, or repeated shaking/shiveringMuscle painSore throatNew loss of taste or smellFeeling weak or fatiguedRunny or congested noseDiarrhea
No
By clicking submit, I acknowledge that Pacific Coast Periodontics will use this information to comply with the San Francisco Department of Public Health screening requirements.
Should be Empty:

COVID-19 Wellness Form

By clicking submit, I acknowledge that Pacific Coast Periodontics will use this information to comply with the San Francisco Department of Public Health screening requirements.