Patient Forms

We are in the process of moving our forms to paperless.  Feel free to bring your own device to the appointment in case you need to sign anything.  Don't worry if you don't, we will provide you with an iPad which is thoroughly cleaned after each patient.  

At Santa Rosa Dentistry, we strive to make your life easy!  Simply fill out your patient forms here and get a head start on your appointment.  


The patient questionnaire form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weakened or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to us any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

We ask that all patients coming in for an appointment fill out a COVID-19 Screening Questionnaire a few days before their appointment as well as upon their arrival.  This two step screening process will allow us to reschedule your appointment to another time if needed.  

COVID-19 Screening Questionnaire



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