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Orthodontic Treatments
Patient
Reviews
About
- Our Doctor
- Our Team
Blog
Contact
- Office in Anacortes
- Office in Bellingham

Orthodontic Treatments
Patient
Reviews
About
- Our Doctor
- Our Team
Blog
Contact
- Office in Anacortes
- Office in Bellingham

Schedule A Consultation

Minor New Patient Intake Form

Minor New Patient Intake Form

Full Name(Required)

First

Preferred Name(Required)

First

Appointment Date(Required)

MM slash DD slash YYYY

Age(Required)

Birthdate(Required)

MM slash DD slash YYYY

Gender @ Birth(Required)

Preferred Pronouns

Patient Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Parent 1

Parent 's Name(Required)

First Last

Parent Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Cellular(Required)

Email(Required)

Parent's Employer(Required)

Department Position

Phone(Required)

Step Parent

Parent 2

Parent 's Name

First Last

Parent Address

Street Address City State / Province / Region ZIP / Postal Code Country

Cellular

Email

Parent's Employer

Department Position

Phone

Step Parent

This field is hidden when viewing the form

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Parent's Marital Status(Required)

Domestic Partner

Who is responsible for account

If divorced, patient lives with

Name of relative or friend not at the same address

Relationship

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Do you have insurance that covers orthodontia?(Required)

Yes

No

Primary

Primary insured person(Required)

SS#/ID(Required)

Birthdate(Required)

MM slash DD slash YYYY

Name of ins Co(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Group Number

Phone

Secondary

Secondary insured person

SS#/ID

Birthdate

MM slash DD slash YYYY

Name of ins Co

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Group Number

Phone

Consent(Required)

Consent

I authorizes release of information for insurance claim processing, and for any insurance benefit to be paid directly to Dr. Derek Damon

This field is hidden when viewing the form

Section Break

Name of other family members treated in our office

Relation

Family Dentist(Required)

Date of last appointment

MM slash DD slash YYYY

Principal Complaint

Whom shall we thank for recommending us?

Is patient in good health?(Required)

Yes

No

History of thumb sucking(Required)

Yes

No

Physical or medical difficulties(Required)

Yes

No

Is the patient mouth breather?(Required)

Yes

No

Chronic illness treated by a physician(Required)

Yes

No

Is there a speach problem(Required)

Yes

No

Taking any medication(Required)

Yes

No

Have tonsils/adenoids been removed(Required)

Yes

No

Taking osteoporosis medication(Required)

Yes

No

Autism(Required)

Yes

No

Allergic to medication/Specify(Required)

Yes

No

ADHD(Required)

Yes

No

Jaw joints click or pop(Required)

Yes

No

Allergic to metal or latex/Specify(Required)

Yes

No

Required antibiotics before detal appt(Required)

Yes

No

Pain in jaw joints(Required)

Yes

No

Does patient grind his/her/their teeth(Required)

Yes

No

Hepatitis(Required)

Yes

No

HIV+ / AIDS(Required)

Yes

No

Frequent Headaches/ear aches(Required)

Yes

No

Other medical information we should be aware of

STATEMENT OF PRIVACY PRACTICES

Bellingham Office

3400 Squalicum Pkwy #101, Bellingham, WA 98225

Anacortes Office

1220 22nd St STE A, Anacortes, WA 98221

Thank you for visiting the website of Derek Damon Orthodontics, the office of Derek R. Damon, DDS, a respected provider of orthodontic care in your local community. Located in Bellingham and Anacortes, Washington, our practice's top priority is to provide you the highest quality orthodontic care in a friendly, comfortable environment.

Quick Links

Orthodontic Treatments
Patient
Reviews
About
- Our Doctor
- Our Team
Blog
Contact
- Office in Anacortes
- Office in Bellingham

Orthodontic Treatments
Patient
Reviews
About
- Our Doctor
- Our Team
Blog
Contact
- Office in Anacortes
- Office in Bellingham

Office Hours

Bellingham:
Monday – Thursday/Patient Hours: 8:00 – 5:00

Anacortes:

Tuesday and Wednesday/Patient Hours: 8:30 – 5:00

Monday and Thursday/Reception Hours: 9:00 – 4:00

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Bellingham Location: 3400 Squalicum Pkwy #101, Bellingham, WA 98225 | Phone: (360) 676-6060
Anacortes Location: 1220 22nd St STE A, Anacortes, WA 98221 | Phone: (360) 293-2888

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STATEMENT OF PRIVACY PRACTICES
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