COVID-19 Wellness Form
Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?
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.
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)
Shortness of breath
Unexplained fever(≥100º F)
Chills, or repeated shaking/shivering
New loss of taste or smell
Feeling weak or fatigued
Runny or congested nose
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.
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