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Orthodontics Prescreening Survey

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Orthodontics PreScreening Survey

Prescreening questions to send patients prior to arriving to their scheduled appointment.

Page 1

Please answer the following questions to help us better understand your orthodontic needs.

Email*

What is your full name?*

What is your date of birth?*

What is your phone number?*

What is your address?*

What is the name of your general dentist?*

Description:This Orthodontics PreScreening Survey is designed to help you prepare for your upcoming appointment. By answering these questions in advance, you can help us ensure that your visit is as safe and efficient as possible. We appreciate your cooperation in helping us maintain a healthy environment for all of our patients and staff.

Are you scheduled for an upcoming orthodontic appointment? If so, this prescreening survey is an important step in preparing for your visit. By answering questions about your health and recent travel, you can help us identify any potential risks and take appropriate precautions. Our goal is to provide you with the best possible care while minimizing the risk of exposure to COVID-19 and other illnesses. Thank you for your cooperation in helping us maintain a safe and healthy environment for everyone.

What is your full name?*

What is your date of birth?*

Select date

What is your gender?*

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What is your full name?*

What is your date of birth?*

Select date

What is your gender?*

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Full Name*

Employee ID*

Date of Request*

Select date

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Student ID Number*

Date of Birth*

Select date

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