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.* NameThis field is for validation purposes and should be left unchanged.