Patient Wellness Survey

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All POSITIVE COVID-19 test results must be reported to our office within 2 days of results.

Patients must brush before coming into the office.

This form allows us to screen for illnesses, including the virus knows as COVID-19, in an effort to keep all our patients and team safe. Please fill this form out prior to your appointment time.

Please note: If you are experiencing non-infectious coughing or other non-infectious symptoms (per physician), it will need to be controlled with cough suppressant, allergy medication, etc. We cannot have active coughing, sneezing, runny noses in the clinic.

Patient Name *

Your Name (if different)

If you are the patient, it's okay to leave blank.

If patient is a minor, how should they be discharged? *

If patient is being brought to their appointment by someone other than guardians we have on file, please have them text the office @ 619-335-6761 with the patient name in the text, when they arrive.

Patient can leave independently.

Patient will call me at the end of appointment.

Staff needs to call me at the end of appointment.

I'll be waiting at the door.

Does not apply (I brought myself)

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