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Patient Forms

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Woman looking at website on her phoneTo save you time at your initial visit, we have provided the necessary new patient forms below. Simply download, print and complete the forms (PDF), and please e-mail them once completed to our Treatment Coordinator at treatment@diersorthodontics.com.

All patients should complete a new patient form, the HIPPA privacy policy and a sleep assessment. Adults or children, if you are experiencing any jaw problems, such as pain, noise in the joint, or headaches, please complete the TMJ form as well.

Adults—Please complete a new patient form and sleep form.

Please complete this adult new patient form.

Children—Please complete a new patient form and sleep form.

Please complete this child new patient form.

If you have any TMJ symptoms, please complete the TMJ form.

This is the TMJ form.

Our two page printable HIPPA privacy policy & verification page can be found here.
Our Records Release page can be found here.

If you need any assistance, or have any questions, please do not hesitate to call our office at (513) 829-4400.






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