John S. Woo


Orthodontics for Children, Teens & Adults

Sebastopol Orthodontics - Orthodontist in Sebastopol, CA, Orthodontics in Sebastopol, Santa Rosa, Windsor

Health History Form

/Health History Form
Health History Form2018-07-04T21:46:12+00:00

Please Fill out and submit our secure online Health History Form below.

If you prefer, you can download the Health History Form, open it in Adobe Acrobat Reader and fill it out on your computer. Then save it and email it to us at

You can also print the Health History Form.PDF , fill it out and bring the completed copy with you to your next appointment.

These patient forms will help us provide the individual care you or your child needs.

  • Patient Information

  • Responsible Party Information

  • Responsible Party, Other

  • Dental Insurance Information

  • 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.