Wellness Form

    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


    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 or 2 meters or closer for more than 15 minutes total in a 24 hour period.

    Have you traveled domestic or international in the past 14 days outside of your typical living area, out of state, or out of the country, or have you attended gathering or events with people from outside of your household i.e. people you don't currently live with where you were within 6 feet of others while not wearing face coverings for 15 minutes total over 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 attributed to existing conditions, for example allergies.

    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.

    After you click send please look at the small "loading wheel" on the right of the button and wait until the form has been submitted. If there are any errors, please review the form again, make sure they are fixed, and then submit. The form has only been successfully submitted once the small spinning wheel on the right of the submit button shows a successful submission. Thank you!