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Dental Implants
Robotic Surgery
Am I A Candidate?
Transformations
Our Advantage
Patient Center
Complimentary Consultation

Dental Implants
Robotic Surgery
Am I A Candidate?
Transformations
Our Advantage
Patient Center
Complimentary Consultation

Wellness Form - San Francisco, CA

Wellness Form

Schedule A Consultation

Wellness Form

Do you have cough? *

Yes No

Do you have fever now or in the past 14-21 days? *

Yes No

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days? *

Yes No

Are you experiencing shortness of breath or difficulty breathing? *

Yes No

Have you experienced recent loss of taste or smell? *

Yes No

Are you over the age of 60? *

Yes No

Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *

Yes No

Have you traveled to any region affected by COVID-19 in the past 14 days? (As relevant to your location) *

Yes No

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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

Contact Us

450 Sutter St, Suite 1905
San Francisco, CA 94108
New Patients: 415-795-8866
Current Patients: 415-391-7751

Fax: 415.391.7357

Email: [email protected]

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