Address:
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

Contact Us

COVID-19 Risk Assessment

Patient Name

Phone Number

Have you had a fever, cough, shortness of breath, sore throat, any new loss of smell or taste, muscle pain, or flu-like symptoms in the past 14 days?

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

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

Yes

If yes, where have you traveled?

Have you been in contact with anyone who has traveled to Sonoma County or California from somewhere else?

Yes

If yes, from where?

I agree to contact Sonoma Valley Oral Surgery & Dental Implants if I develop any of these symptoms within 14 days of my last visit to an OMS office.

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Last Name

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