Elevated Orthodontics Pre-Appointment Survey

Parent or legal guardian’s name*

First Last

What is the patient's name?*

First Last

Who is filling out this check-in?*

Adult/Guardian
Child/Dependent

Describe the car you’re in, so we can find it to check you in.*

Have you, or anyone with you, traveled overseas in the last 14 days?*

Yes
No

Have you, or anyone with you, traveled within the USA by air, bus, or train in the last 14 days?*

Yes
No

Have you, or anyone with you, been tested for COVID-19 and are awaiting the results?*

Yes
No

Have you, the patient, or any of your recent acquaintances tested positive for COVID-19 or any other diseases in the last 14 days?*

Yes
No

Have you come into contact with anyone experiencing symptoms of COVID-19 in the last 14 days?*

Yes
No

Have you, the patient, or anyone with you, experienced a persistent cough in the last 14 days?*

Yes
No

Have you, the patient, or anyone with you, experienced shortness of breath in the last 14 days?*

Yes
No

Have you, the patient, or anyone with you, experienced chest pressure in the last 14 days?*

Yes
No

Have you, the patient, or anyone with you, had a fever in the last 14 days?*

Yes
No

Is the patient older than 65?*

Yes
No

Do you have any chronic immune or systemic conditions?*

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.

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