Sonoma Office

378 Perkins St
Sonoma, CA 95476

Phone:
(707) 996-4519

Hours:
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM

Napa Office

3301 Villa Lane
Napa, CA 94558

Phone:
(707) 255-5033

Hours:
Mon-Fri: 8:00 AM -5:00 PM

COVID-19 Risk Assessment

Patient Name

Phone Number

Are you fully vaccinated for COVID-19?

Yes

Do you have a fever or above normal temperature (>100.0 ̊ F)? Take temperature at appointment.

Yes

Are you experiencing more than one of the following symptoms: shortness of breath, dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss of taste or smell?

Yes

Have you been near or had physical contact with anyone who has had these symptoms or has been diagnosed with COVID-19 in the past 14 days?

Yes

Even if you don’t currently have any of the above symptoms, have you experienced more than one of these symptoms in the last 14 days?

Yes

Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19?

Yes

Have you been tested for COVID-19 in the last 14 days?

Yes

What is the result of the testing?

Positive

Negative

Unknown

If still waiting on results, schedule appointment after results are known.

Have you traveled out of California in the last 14 days?

Yes

If yes, where have you traveled?

I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had close contact with tested positive for COVID-19 within 2 days.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself or the entity I am authorized to represent.