Palleck Orthodontics is now Woodstock Orthodontics!

As Dr. Sonia Palleck shifts into retirement, Dr. Loren Chan and the entire team are carrying her legacy into the future, with the same passion, care and commitment to our patients.

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630 Dundas St Woodstock ON N4S 1E2 CA
(519) 533-0303

About
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Children
Teens
Adults
Patients
Contact

Book Consultation

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New Patient Form

Once you've booked your first appointment at Woodstock Orthodontics, please complete out our new patient form below.

Patient Information

Legal Name *

Preferred Name

Birth Date *

Gender Identification

Preferred Pronouns

Address *

City *

Postal Code *

Phone *

Other Phone (If appicable)

Email Address *

How did you hear about us?

Has anyone else in your family been examined here? *

If yes, who?

Primary Dentist *

Date of Last Visit *

Physician *

Patient Height *

Parent Height

Parent Height

Parent/Guardian Information

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

Parent /Guardian Name *

Phone (If different from above)

Address (If different from above)

Employer

Email

Parent/Guardian Name

Phone (If different from above)

Address (If different from above)

Employer

Email

Insurance

Primary Insured

Birth Date

Contact #

Insurance Company

Plan/Group

Certificate/ID

Secondary Insured

Birth Date

Contact #

Insurance Company

Plan/ID

Certificate/ID

Medical History

Please check off your main concern(s) *

Spaces

Crowding

Appearance

Jaw Pain

Tooth Wear

Other

If other, please indicate

Have you had prior orthodontic treatment? *

Yes

No

If yes, what was performed?

Do you have a history of any of the following? (Check all that apply) *

Abnormal Blood Pressure

ADHD/ADD

Anemia

Anxiety

Artificial Joint

Autism

Behavioural Concerns

Clench/Grind Teeth

Cold Sores

Diabetes

Difficulty Breathing Through Nose

Discomfort with Bite

Eating Disorders

Epilepsy/Seizures/Convulsions

Frequent Headaches

Heart Issues/Pacemaker/Murmur

Hepatitis

HIV/AIDS

Hormone Therapy

Latex Allergy

Major Fall or Accident involving Head or Face

Metal Allergy

Mood Disorder

Nail or Lip Biting

Noises or Discomfort in or Around Jaw Joints

Pregnant

Chemotherapy / Radiation

Sinus Trouble

Sleep Apnea/Snoring

Smoking/Vaping

Speech Problems

Thumb/Finger sucking

Tonsils/Adenoids removed

N/A

Other Conditions

Medications

Previous Surgeries

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

Yes my information is correct

Patient/Parent/Guardian Signature *

Date *

Spam Blocker

No Referral Needed

Whether you’re considering treatment for child, your teen, or yourself, our clinic in Woodstock can help! Give us a call today to get started on your orthodontic journey.

Book Consultation Call (519) 533-0303

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Location

630 Dundas St Woodstock ON N4S 1E2 CA
Hours
- Monday:08:00 am - 04:00 pm
- Tuesday:08:00 am - 04:00 pm
- Wednesday:08:00 am - 04:00 pm
- Thursday:08:00 am - 04:00 pm
- Friday:08:00 am - 03:00 pm
- Saturday:Closed
- Sunday:Closed
*Monday and Friday are closed on alternating weeks.
Phone

(519) 533-0303

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Corus Orthodontists. Managed with Tymbrel.