Appointment check-in Ready to check-in? Please complete our appointment check-in form below. If you have any questions call us on (615) 348-1008. HiddenVersion historyv2.2 : Removing DOB, Copy to options and change on mobility risk (2022-04-01) v2.1 : Mobility risk question added (2022-01-18) v2.0 : COVID-19 Screening was removed (2021-03-18) v1.6 : Updated CDC Guidelines (10 days quarantine) v1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header, vehicle color and no captcha (change), 2020-06-04 v1.2 : DOB changed to date dropdowns (change) v1.1 : Pre-med question (add)Patient name:(* required) First Last Did the patient take a pre-med prior to this appointment?(* required) Yes No If (yes) please inform medication name, dose and time:(* required) Mobility Concerns* Please let us know if the patient needs to be transported in a wheelchair and we will be happy to supply one. Driver/caregiver contact info:Driver name:(* required) Use 'self' if you are drivingDriver phone number:(* required)Relationship to patient: Ignore this field if you are the patientVehicle color:(* required)please select a colorBlackBlueBrownGold/YellowGrayGreenRedSilverWhiteOtherVehicle color (other):(* required) Vehicle (make and model):(* required) SubmitAny questions?Please sign(* required)Important: You consent to sign this document electronically.
