Patient Name* First Last Phone Number*Appointment Date* MM slash DD slash YYYY Do you have or have you had any respiratory illness symptoms (cough, runny nose, sore throat, fever above 100 degrees) in the past 10 days?* Yes No If yes, please describe your symptoms.Have you been in contact with someone who has tested positive or suspected they were positive for COVID in the past 10 days?* Yes No Have you tested positive or are you awaiting test results for COVID within the last 10 days?* Yes No I understand, if the answer to any of the above questions changes between now and my appointment, I may not be able to be seen. I agree to contact Merry Dental prior to my appointment to discuss keeping the appointment. Intitial for agreement.*PhoneThis field is for validation purposes and should be left unchanged.
