Patient Name* First Last Email* Appointment Date* MM slash DD slash YYYY Do you or have you had a fever of above 100 degrees in the past 14 days?* Yes No Are you experiencing shortness of breath or other difficulties breathing?* Yes No Do you have a sore throat, cough or runny nose?* Yes No Are you experiencing any other flu-like symptoms, such as gastrointestinal upset, headache, body aches or fatigue?* Yes No Have you experienced a recent loss of taste or smell?* Yes No Have you been in contact with someone who has tested positive for or suspected they were positive for COVID-19 in the past 14 days?* Yes No Have you tested positive for COVID-19 or are you awaiting test results for COVID-19 within the last 14 days?* Yes No Have you been vaccinated against COVID-19?* Yes No If yes, what was the date of your final dose? Have you traveled by plane in the past 14 days?* Yes No I understand a positive response to any of the above questions will require a discussion with the dentist before proceeding with dental treatment.*Initial for Consent I agree to notify Merry Dental Care Center if any of my responses to the above questions change between now and my scheduled appointment.*Initial for Consent I agree to notify Merry Dental Care Center if, within 14 days, I become ill with COVID-19 symptoms or test positive for COVID-19.*Initial for Consent EmailThis field is for validation purposes and should be left unchanged.
