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For Your Free Smile Evaluation

braces consultation with fair oaks citrus heights orthodontist
916.966.5517
8035 Madison Ave Suite G-2, Citrus Heights, CA 95610

Please Complete and Submit Prior to Your Child’s Scheduled Appointment. Thank you!

Child New Patient Form

Please fill out this form prior to your Complimentary Examination. We look forward to meeting you!

Patient Name(Required)
Patient Photo
Accepted file types: jpg, jpeg, png, gif.
Date of Birth(Required)
Address(Required)

Parent / Guardian Information

Primary Contact Name(Required)
I consent to receiving appointment reminders via:
Secondary Contact's Name
I consent to receiving appointment reminders via:
Legal Guardian's Name
Able to discuss treatment?
Able to schedule appointments?
Able to approve future x-rays?
Able to get reminders?

What Brings You to Our Office?

If you have had a previous orthodontic consultation or treatment, please answer the following:
Name of Orthodontist / Practice
When / Where
Have you hade X-Rays taken within the last 6 months?
Was there anything that you did or did not like about their office?
 
What Concerns You Most About Braces? (Check All that Apply)
Do you anticipate a move or transfer in the future?
Has patient been teased at school due to appearance of teeth?
Has a Dentist ever placed a retainer or space maintainer?

Dental History

Date of Your Dental Cleaning & Check-Up
Does patient breathe predominantly through the mouth?
Does patient snore?
Are you aware of any tooth grinding or clenching during the day or night?
Does patient have any speech problems?
Does patient have pain or clicking when opening or closing the mouth?
Are you aware of noises in the jaw joints?
Has the patient had any severe head or face injuries? If yes, when / what?
Have any teeth been injured or chipped due to accidents? If yes, when / where?
Does patient have any difficulty in chewing or swallowing food?
Has patient been informed of any extra or missing teeth? If yes, please explain:
Have you any teeth (baby or permanent) been removed by extraction? If yes, why?
If any other family members have had orthodontic treatment, please note:
If you have any other family members who could benefit from orthodontic treatment, please note:

Medical History

Have you been diagnosed or treated for:
Are you presently under a physician's care?
Are you currently taking any medications or drugs?
Have you ever had an unusual reaction or allergic reaction to any medications or substances?
Have you ever had major surgery?
(Girls) Menstruated?
(Boys) Voice Change?
Do you have a chronic problem with:
Have you ever had a sleep study?
Do you have sleep apnea?
Do you have a CPAP or BiPAP?

Dental / Orthodontic Benefits

Welcome! If you have Health or Dental / Orthodontic Benefits we will be happy to cooperate with you and your benefits carrier to see that you receive proper benefits from them. At the present time, our practice is not affiliated with or participating with any HMO plans. Patients who have orthodontic benefits should remember that professional services are rendered and charged to the patient, not their benefit (insurance) company. We cannot render services on the assumption that our charges will be paid by an insurance company. You will be responsible to continue making your contractual monthly payments, however we are happy to bill your insurance and will apply any payments received toward your contract balance. If your account has been paid in full and we receive additional insurance payments after the fact, you will be issued a refund for any additional coverage / payments received. Some health insurance programs provide limited benefit coverage for orthodontics. Some provide no coverage. Patients attempting to bill their medical insurance for orthodontic benefits may do so independently. Patients are responsible to Dr. DeLurgio for their services.

Primary Benefit Information

Insurance Card Front
Accepted file types: jpg, jpeg, png, gif.
Name of the Subscriber (Covered Individual)
Address of the Subscriber

Secondary Benefit Information

If the Patient has dual insurance (is covered by a second benefit policy), please complete the following for the second insurance information:
Insurance Card Front
Accepted file types: jpg, jpeg, png, gif.
Insurance Card Back
Accepted file types: jpg, jpeg, png, gif.
Name of the Subscriber (Covered Individual)
Address of the Subscriber

Release, Authorizations, and Acknowledgments

I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering benefit claims. I understand that my dental care benefit provider may pay less than the actual bill for services. I understand that I am financially responsible for my payment of services not paid, in whole or in part by my dental/orthodontic benefit provider. I attest to the accuracy of the information provided. I have read and understand the above benefit policy and agree to it. I hereby authorize payment of dental benefits directly to the above named dentist. A copy of this authorization is valid.(Required)
I have reviewed the above information in it's entirety and it is true and correct. If there are any later changes to this history record, I will so inform the practice. I hereby authorize necessary credit information to be obtained by your office. I authorize the taking of diagnostic records for an initial diagnosis, if needed.(Required)
Acknowledgement of Receipt of Notice of Privacy Policy(Required)
https://bit.ly/DeLurgio_Notice_of_Privacy_Practices
I authorize the video and / or audio recording of my examination, consultation and or treatment visits for educational purposes.

Optional Uploads for Files, Reports, X-Rays or Photos

If you have any additional records that you would like to send in advance of your initial exam, please upload them below.
Images
Accepted file types: jpg, jpeg, png, gif.
Max. file size: 8 MB.
Date(Required)

SEE WHY PATIENTS LOVE OUR AWARD-WINNING SACRAMENTO ORTHODONTIST FOR BRACES & INVISALIGN
"My orthodontic treatment was great at Dr. DeLurgio's office. The staff is great and Dr. DeLurgio is very kind and informative. Her work speaks for itself. I appreciate her attention to detail and most of all, the quality of her work. I can't stop looking at my teeth. I didn't know they look that good."*
- Rachaad H.
5 star
"I am a local dental hygienist and I only wanted the best for my daughter. Dr DeLurgio and Dr Blom are the BEST. The care that they took was incredible and her teeth are perfect. I would highly recommend them to everyone...in fact I do to all of my patients in need of ortho care. Thank you Dr DeLurgio and Dr Blom!!"*
- Keri O.
5 star
"I wasn’t very excited when I found out I had to get braces for what was estimated to be two years. Thankfully Dr. Delurgio introduced me to the Acceledent device which saved me an entire year. My braces are off earlier than I expected and my teeth and bite are perfect. I couldn’t be happier with the results."*
- Catie M.
5 star
"My younger son's braces were off earlier than expected and he loved the result of how his teeth were aligned. It's really worth to see these Drs Blom and Delurgio. They're so nice they made my son comfortable and really professional including their staff. Sadly, Dr Blom already retired from his practice but with Dr Delurgio now in-charge I'm so confident with her that my other son who just started his braces late last year is getting improvement with his teeth."*
- Gem R.
5 star
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*The reviews on this page are from actual patients of DeLurgio. Individual results may vary. Reviews are not claimed to represent results for everyone.
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For Your Free Smile Evaluation

citrus heights ca orthodontist braces consultation
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916.966.5517
Contact Our 5-Star-Rated Citrus
Heights, CA Orthodontist Today!
8035 Madison Avenue Suite G2,
Citrus Heights, CA 95610
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Our Fair Oaks, CA, orthodontist and Citrus Heights, CA, orthodontist offer the most advanced braces for children and braces for adults. These types of braces include metal braces, clear braces, self-ligating braces and Invisalign.
Come experience DeLurgio Orthodontics! You will see for yourself that our greater Sacramento orthodontist offers effective and affordable braces in Citrus Heights, Fair Oaks, Folsom, Orangevale, Carmichael, Rancho Cordova, Gold River, Roseville, Granite Bay and Sacramento, CA.
Call 916.966.5517 today for your free braces consultation at our Citrus Heights orthodontic office.
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