Woloshyn & Nordberg Orthodontics Check-In

What is the patient's name?*

First Last

Parent or legal guardian's name

First Last

Who is filling out this check-in?*

Adult/Guardian
Child/Dependent

What spot number are you parked in?*

Which location are you checking into?*

Please provide your cell phone number for the office to contact you.*

Do you, the patient, or anyone with you currently have a fever?*

Yes
No

Do you, the patient, or anyone with you have a cough or experiencing any shortness of breath*

Yes
No

Do you, the patient, or anyone with you have any other flu like symptoms such as headache, fatigue, or sore throat?*

Yes
No

Have you, the patient, or anyone with you noticed a sudden loss or change with your sense of taste or smell?*

Yes
No

Have you come into contact with anyone experiencing symptoms of COVID-19 in the last 10 days?*

Yes
No

Consent to Treatment*

As with any illness, anyone can be exposed to COVID-19 at any time or place. We have always followed all recommended guidelines, laws and disinfection protocols in our office.
Even with our careful attention, the chance remains that you could be exposed in our office, just as you might be anywhere.

We've taken significant measures to keep you safe, however, it's not always possible to maintain a constant distance between the patient, our office staff, and sometimes other patients.

Although exposure is unlikely, do you accept the risk and consent to treatment?

Parent/Guardian Signature*

By signing the document above, and filling out this form, I confirm that I understand the questions presented to me and that I've answered all these questions honestly. I also understand that these answers may result in being asked to reschedule today's appointment. I confirm that I am not a minor, am the legal guardian of this patient, or am an adult patient filling this out for themselves.

Phone

This field is for validation purposes and should be left unchanged.