Patient Name* First Last Phone*Email* Do you or have you had a fever of above 100 degrees in the past 14 days?*YesNoAre you experiencing shortness of breath or other difficulties breathing?*YesNoDo you have a sore throat, cough or runny nose?*YesNoAre you experiencing any other flu-like symptoms, such as gastrointestinal upset, headache, body aches or fatigue?*YesNoHave you experienced a recent loss of taste or smell?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders?*YesNoHave you been in contact with someone who has tested positive for or suspected they were positive for COVID-19 in the past 14 days?*YesNoHave you tested positive for COVID-19 or are you awaiting test results for COVID-19 within the last 14 days?*YesNoHave you traveled out of the cities in the past 14 days?*YesNoI understand a positive response to any of the above questions will require a discussion with the dentist before proceeding with elective dental treatment.*Initial for ConsentI 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 ConsentI 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 ConsentEmailThis field is for validation purposes and should be left unchanged.
