Appointment check-in - Triax Dental - Special Needs and General Dentistry in Nashville, TN

Ready to check-in?

Please complete our appointment check-in form below. If you have any questions call us on (615) 348-1008.

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Patient name:*

First Last

Patient date of birth:*

Did the patient take a pre-med prior to this appointment?*

Yes
No

If (yes) please inform medication name, dose and time:*

Driver/caregiver contact info:

Driver name:*

Use 'self' if you are driving

Driver phone number:*

Relationship to patient:

Ignore this field if you are the patient

Vehicle color:*

Vehicle color (other):*

Vehicle (make and model):*

COVID-19 Screening

Does the patient have a fever today or within the last 10 days?*

Yes
No

Is the patient having shortness of breath or other difficulties breathing?*

Yes
No

Does the patient have a cough?*

Yes
No

Does the patient have any other flu-like symptoms, such as gastrointestinal upset, headache/body ache or fatigue?*

Yes
No

Has the patient experienced recent loss of taste or smell?*

Yes
No

Was the patient in direct contact with any confirmed COVID-19 positive people in the last 10 days?*

Yes
No

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Does the patient have heart disease, lung disease, kidney disease or any auto-immune disorders?*

Yes
No

Positive responses to any of these COVID-19 questions would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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