Check-in Questionnaire

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Please complete this questionnaire to help your visit run smoothly.

Updated 12/6/2023

Please complete this form on the day of your visit before you enter our office.

Name of patient *

Date of office visit *

Is the patient sick? *

Please postpone orthodontic treatment if the patient is not feeling well. Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.

No symptoms today and no symptoms within the past 10 days.

Yes, the patient has had symptoms and/or a positive SARS-CoV-2 viral test within the past 10 days.

Is anything loose, broken, or bothering the patient? *

Nothing is loose, broken, or bothering the patient.

Other:

Where will accompanying family members be during the patient's appointment? *

Family members will be physically present during the patient's procedure. Within the past 10 days, the companions have NOT had symptoms, including fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea.

Family members will wait in their car during the patient's procedure.

Name of person signing on behalf of the patient *

Electronic signature consent *

I consent to the use of electronic records and electronic signatures in place of written documents and handwritten signatures as described at https://www.smilelogicortho.com/esign/

Required

Acknowledgement *

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including an orthodontic office, and I have been informed that my orthodontist desires to protect the safety of the orthodontic office and the patients, staff and other individuals who come upon the premises.

Required

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