Please fill out our secure Health History Form

Please take a moment to fill out our electronic Health History form before your initial consultation. Click HERE if you prefer to print the form and bring it to the exam. 

  • Patient Information

  • MM slash DD slash YYYY
  • Responsible Party Information

  • Responsible Party, Other

  • Dental Insurance Information

  • MM slash DD slash YYYY
  • Patient's Medical History

  • Please answer yes or no to the following:
  • I authorize John S Woo, DDS MS to release any information including diagnosis and the records of any treatment or examination rendered to my child or me during this period of such dental care to third party payors and/or other health practitioners. I give release for the office to use photographs and the first initial or name of my child or self for office bulletin displays and/or office websites. I agree to be responsible for payment of all services rendered on my behalf or my my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
  • MM slash DD slash YYYY

Filling this form out for your child? We would love to get to know them prior to their first appointment, so have them fill out the Just For Kids form HERE!