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Patient Information

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In Office Visits

At Creekside Orthodontics, patients are treated with respect, professionalism, and sensitivity to their needs. Our team understands the expectations of patients and families and strives to provide an exceptional experience. From the moment of entry, patients are made to feel comfortable, welcome, and appreciated. Our team works efficiently to avoid interfering with patients’ busy schedules and ensure that appointments are appropriately scheduled. Our office environment is friendly, inviting, and professional, recognizing that each patient has unique needs and expectations.

New Patients

If you’re ready to set your first appointment, please fill out our online form or give us a call at 707-452-1111

We also ask that you complete the form below and submit digitally or download, print, and fill out our new patient form and bring to your first appointment to help expedite your visit.

FILLABLE MEDICAL HISTORY FORM

PATIENT INFORMATION

Items marked with an asterisk (*) must be completed

Who will be accompanying your child at the New Patient Exam (please complete if patient is under 18)

MOTHER'S INFORMATION (if patient is under 18)

FATHER'S INFORMATION (if patient is under 18)

Who is responsible for making appointments? (if patient is under 18)

PERSON RESPONSIBLE FOR ACCOUNT

The parent or Guardian who accompanies the child is responsible for payment. Our office is HIPPA Compliant and is committed to meeting or exceeding the standards of infection control madated by OSHA, the CDC and the ADA.

EMERGENCY CONTACT

PRIMARY INSURANCE

SECONDARY INSURANCE

MEDICAL HISTORY

Please fill out this section to the best of your knowledge.

GENERAL HEALTH

With your permission we may take some diagnostic images (x-rays and photographs) at your initial visit so that we may better evaluate your needs. These are for internal use only and there will be no charge for these at this time. If your choose to have treatment or wish to take the images for use outside our office we will charge our normal fees for these images. In requesting examination and treatment, I authorize the release of all information, including radiographs, relating to the examination of treatment and to insurance companies. I also authorize the release of such information to any peer review or committee or state or local dental association which may request it. Radiographs and photos will be taken at time of exam and will only be billed if treatment is elected or if radiographs are released from office. I hereby authorize payment directly to Creekside Orthodontics or their associate the group insurance benefits otherwise payable to me, but not to exceed the actual charge for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits. I understand that where appropriate, credit bureau reports may be obtained.
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure interface.

Or download and fill out medical history form:

Adult Medical History Form

Child Medical History Form

Financial Information

Our practice accepts most major credit cards and PPO insurance plans.

If you have insurance that will be covering any portion of your orthodontic treatment, our office staff is always available to help you with insurance claims and paperwork.

Payment Plans

We offer patients affordable payment plans through OrthoBanc.

OrthoBanc logo

Emergencies

We understand that orthodontic emergencies can happen unexpectedly, and we are here to help. If you are experiencing severe pain or a painful appliance problem that you cannot fix yourself, please call our office to schedule an appointment. However, if you have a loose piece that you can remove, keep it in a plastic bag or envelope and bring it with you to your next appointment. For braces that are poking you, simply apply soft wax to the piece that’s sticking out. If the wire has slid to one side, use needle-nosed pliers to pull it back to the other side, replacing it in the tube on the back tooth.

After addressing your immediate discomfort, it is crucial to still contact our office to set up a repair appointment. Leaving the damaged appliance for an extended period could disrupt your treatment plan.

    Common Problems & Home Remedies

    For more information about our office, please contact us at 707-452-1111 today!

    Orthodontist in Vacaville, CA | Creekside Orthodontics

    2070 Peabody Rd #700
    Vacaville, CA 95687

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    Phone

    707-452-1111
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    Hours
    Monday 8:00am to 5:00pm
    Tuesday 8:00am to 5:00pm
    Wednesday 8:00am to 5:00pm
    Thursday 7:30am to 4:00pm
    Friday - Sunday  Closed