COVID-19 Risk Assessment

Patient Name *
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Phone Number *
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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? *
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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? *
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Have you traveled out of Ventura County in the last 14 days? *
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Have you been in contact with anyone who has traveled to Ventura County from somewhere else? *
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I agree to contact Anacapa Dental Art Institute if I develop any of these symptoms within 14 days of my last visit to an Anacapa Dental office.
First Name
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Last Name
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Email
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PHONE

(805) 988-3317, (805) 988-3320

 

ADDRESS

2821 North Ventura Road, Bldg H
Oxnard, CA 93036

HOURS

Monday – Friday: 8:00 am – 5:00 pm