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. Version historyv1.6 : 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:* First Last Patient date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Did the patient take a pre-med prior to this appointment?*YesNoIf (yes) please inform medication name, dose and time:* Driver/caregiver contact info:Driver name:*Use 'self' if you are drivingDriver phone number:*Relationship to patient:Ignore this field if you are the patientVehicle color:*please select a colorBlackBlueBrownGold/YellowGrayGreenRedSilverWhiteOtherVehicle color (other):*Vehicle (make and model):* COVID-19 ScreeningDoes the patient have a fever today or within the last 10 days?*YesNoIs the patient having shortness of breath or other difficulties breathing?*YesNoDoes the patient have a cough?*YesNoDoes the patient have any other flu-like symptoms, such as gastrointestinal upset, headache/body ache or fatigue?*YesNoHas the patient experienced recent loss of taste or smell?*YesNoWas the patient in direct contact with any confirmed COVID-19 positive people in the last 10 days?*YesNoPatients 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?*YesNo Positive responses to any of these COVID-19 questions would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. SubmitAny questions?Do you wish to receive a copy of this form?*YesNoE-mail address:* Please sign*Important: You consent to sign this document electronically.