Check-in Questionnaire
Please complete this questionnaire to help your visit run smoothly.

Updated 12/6/2023
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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.
Is anything loose, broken, or bothering the patient? *
Where will accompanying family members be during the patient's appointment? *
Name of person signing on behalf of the patient *
Electronic signature consent *
Acknowledgement *
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