Patient Forms | Diers Orthodontics

Due to the order signed by the Ohio state Department of Health, beginning at midnight on March 24th, 2020, our office will be closed except for emergencies until at least April 6th.

If we need to inform our patients of further closures mandated by State or Federal Governments, we will update here and via email. Patients may still call to be seen for emergencies but there are going to be guidelines in place for how patient is seen to limit exposure to patient and office staff. Please call 513-777-9040 for emergencies and thank you in advance for your understanding and cooperation in this ever evolving matter.

From the entire office, please follow the state order and be safe out there. We are all part of the solution in this matter.

Dr. Nelson R. Diers and Staff

Patient Forms

Already have an appointment?

To 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 bring to your appointment.

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.

Our Mission

To constantly improve the orthodontic experience with superior innovative service.

To positively affect our patients lives with an honest, trusting, and considerate orthodontic team.

To grow together in mind, heart, and spirit with superior management, emphasizing communication, encouragement, kindness, and patience.