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)
1) HIPAA - Notice of Privacy Practices
	HIPAA_Notice_of_Privacy_Practices.doc	42 KB
	HIPAA_Notice_of_Privacy_Practices.pdf	25 KB
	Need to print and sign only the last page!
2) New Patient Evaluation - Child
	New_Patient_Eval_Child.doc	65 KB
	New_Patient_Eval_Child.pdf	163 KB
	OR
3) New Patient Evaluation - Adult
	New_Patient_Eval_Adult.doc	66 KB
	New_Patient_Eval_Adult.pdf	163 KB
2nd Appointment (Orthodontic Diagnostic Records)
1) History Patient Info - Child
	History_Patient_Info_Child.doc	76 KB
	History_Patient_Info_Child.pdf	100 KB
	OR
2) History Patient Info - Adult
	History_Patient_Info_Adult.doc	75 KB
	History_Patient_Info_Adult.pdf	47 KB