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

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.

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.