Pacific Coast Periodontics is taking the current pandemic situation very seriously and strives to protect our patients, staffs and the community by taking extra measures prior to your appointments. This form is required to be submitted twice, 7 days and 2 hours prior to the appointment. Thank you for your cooperation. First name Last name Phone Number Email 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 or 2 meters or closer for more than 15 minutes total in a 24 hour period. YesNo Have you traveled domestic or international in the past 14 days outside of your typical living area? 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 attributed to existing conditions, for example allergies. YesCoughShortness of breathUnexplained feverChills or repeated shaking or shiveringMuscle painHeadacheSore throatNew loss of taste or smellFeeling weak or fatiguedRunny or congested noseDiarrheaNo If you answered yes to any of the above questions, we require you to contact us as soon as possible for further instructions after you submit the 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.