New Patient Forms

The following forms may be printed and completed at your convenience to save you time at the evaluation and orthodontic records appointments. If you have any questions please call the office and we will assist you.

Please arrive 10 minutes prior to your scheduled appointment so we can include these forms in the record prior to Dr. Bentele seeing you.

1st Appointment (Orthodontic Evaluation)
A) HIPAA - Notice of Privacy Practices Size
HIPAA Notice of Privacy Practices (Doc) 44Kb
HIPAA Notice of Privacy Practices (Pdf) 776 Kb

Need to print and sign only the last page!

B) New Patient Evaluation Size
New Patient Eval (Doc) 720 Kb
New Patient Eval (Pdf) 772 Kb
2nd Appointment (Orthodontic Diagnostic Records)
A) History Patient Info Size
History Patient Info (Doc) 636 Kb
History Patient Info (Pdf) 712 Kb
Government Regulations Information Size
Language Assistance Services (Pdf) 445 Kb
Notice of Nondiscrimination (Pdf) 925 Kb

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