Consultation Day Agenda

Welcome to the first day of your orthodontic journey! We are truly excited to have you become a part of the ODO family. Attached you will find an agenda of what your first visit with us will entail. It is our sincere hope that we not only meet but exceed your expectations at every step of your treatment process.

Step 1

Fill out new patient paperwork, which includes a thorough medical history, as well as informed consent forms.

Step 2

Screening Exam with Dr. Jordan

Step 3

Take clinical photos and 2 x-rays

Step 4

Formal consultation, where we will explain treatment options, expected length of treatment, and fee structure

Step 5

Same day start to treatment, if all parties are in agreement!

We look forward to helping you achieve the smile that you’ve always wanted!

Patient Health History Form
What's Important to You?
Please check any of the following that you have had or currently have:
Please check any of the following which apply to you, and add any relevant comments:
Old Dominion Orthodontics

21155 Whitfield Place, Suite 107 Sterling, VA 20165


This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign and date this form.

Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office's privacy notice prior to signing this Consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent.

Thank you for your cooperation. Please let us know if you have any questions.

Patient or Responsible Party Signature

Media Consent

To celebrate your treatment, we would like to ask your permission to place announcements on various media platforms with photos of our patients.

We also use these photos and or/patient testimonials in our marketing and advertising campaigns.

Please sign below if you would like to participate.

Thank you!

I grant permission to Old Dominion Orthodontics to use my photos and/or testimonials for marketing/advertising purposes.

Signature of Patient

Signature of Parent/Guardian