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1610 W Yosemite Ave STE 1 Manteca CA 95337 US

Call (209) 824-7466
Text (209) 299-7066

About
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Children
Teens
Adults
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New Patient Form

After booking your first appointment at Duong Orthodontics, please complete our new patient form below to get started.

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone (Primary) *

Phone (Secondary)

Address *

City *

Postal Code *

Family Physician *

Family Dentist *

Does the patient have any relatives who have had treatment in this practice? *

Yes

No

Unsure

Does the patient have dental insurance that covers orthodontic treatment? *

Yes

No

Unsure

Parent / Guardian Information

If completing this form for a minor, please complete parent / guardian information below.

First Name *

Last Name *

Relationship to Patient *

Phone (If different from above)

Address (If different from above)

Medical History

Have you previously consulted another orthodontist? *

Yes

No

Have you had any previous orthodontic treatment? *

Yes

No

Are you currently taking any medication? *

Yes

No

If yes, please list *

Are you in a high risk group for HIV Infection? *

Yes

No

Allergies *

Yes

No

Do you have a history of any serious illness? *

Yes

No

Have you had injuries to the head? *

Yes

No

Have you been informed of any missing or extra teeth? *

Yes

No

Does the patient have a history of any of the following? (Check all that apply) *

Anemia

Bone Disorders

Diabetes

Epilepsy

Fainting or Dizziness

Heart Trouble

Gland or Endocrine Problems

Rheumatic Fever

Nervous Disorders

Congenital Abnormalities

Emotional Disorders

Tuberculosis

Liver Problems

Blood Disorders

Hepatitis

HIV Infection

Prolonged Bleeding

Kidney Problems

Frequent Colds

Asthma

Ear Infections

Chronic Nasal Obstruction

Mouthbreathing

Adenoid Problems

Tonsillitis

Tongue thrusting

Tooth grinding or clenching

Headaches (frequent)

Muscular soreness around head and neck

Jaw joint clicking of popping

Thumbsucking

Finger sucking

Lip biting or sucking

N/A

Have you received treatment for any of the above problems? *

Yes

No

Have your tonsils been removed? *

Yes

No

Unsure

Have your adenoids been removed? *

Yes

No

Unsure

Dental History

Do you have regular dental checkups? *

Yes

No

Date of Last Checkup *

Tooth Brushing *

After every meal

Once per day

Twice per day

Do you floss? *

Yes

No

Reason for seeking orthodontic consultation? *

I accept to be contacted through email by Duong Orthodontics. *

Yes

No

I hereby acknowledge that the health history provided is correct. *

Yes my information is correct

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No Referral Needed

Whether you’re considering orthodontic treatment for yourself or your child, our Manteca team is eager to provide you with excellent care and communication every step of the way.

Call (209) 824-7466 Hours & Map

Location

1610 W Yosemite Ave STE 1 Manteca CA 95337 US
Hours
- Monday:08:00 am - 05:00 pm
- Tuesday:08:00 am - 05:00 pm
- Wednesday:08:00 am - 05:00 pm
- Thursday:08:00 am - 05:00 pm
- Friday:Closed
- Saturday:Closed
- Sunday:Closed
Phone & Fax

Call: (209) 824-7466
Text: (209) 299-7066
Fax: (209) 824-7510

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