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Patient Screening Form

Patient Information

First Name: *

Last Name: *

Date of Birth: *

  

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No  

Are you/they having shortness of breath or other difficulties breathing? *

Yes No  

Do you/they have a cough? *

Yes No  

Any other flu-like symptoms, such as gastronintestinal upset, headache or fatigue? *

Yes No  

Have you/they experienced recent loss of taste or smell? *

Yes No  

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. *

Yes No  

Is your/their age over 60? *

Yes No  

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

Yes No  

Have you/they traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)? *

Yes No  

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand Rho Family Dentistry has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.

 

Confirmation

 
 

Please wait, it may take a moment to submit your information.

 

Rho
Family
Dentistry
Jeffrey J. Rho, DDS


Call Us (916) 562-2755
2525 K Street, Sacramento, CA 95816-5114

Office Hours



Monday-Thursday: 8AM–5PM

Free Parking


Enter the 2nd floor FREE PATIENT PARKING ramp on K street between 25th and 26th street (across the street from St. Francis).
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