Patient Forms


New to our practice? Please fill out these forms so that we may prepare for your visit!


Please start by filling out our New Patient Medical/Dental History Form, which you can fill out and submit right in our secure online environment. If you prefer to fill out this form in our office, please be sure to allow extra time before your appointment to do so.


A fun form for kids to fill out themselves for their first appointment. Tell us “All About You” so we can get to know you better!

All About You
This one is for the kids! Please print a copy, fill out, and bring to your first appointment.


We strongly believe in the power of orthodontics to change lives, and orthodontics can do so much more than most people realize! Please also fill out the Patient Motivation Questionnaire form before your appointment to help us understand a little more about how we might be able to help you. Please let us know if there is anything about your teeth or facial appearance that you would like to change, or whether you are having any pain or discomfort. Thank you!

Patient Motivation Questionnaire
Please print a copy, fill out, and bring to your first appointment.


Moving or need your records sent to another doctor? Please fill out our Records Request/Transfer Form.

Records Request/transfer Form
Please print a copy, fill out, and bring to our office, or fax to 218-236-0719.


Our current Notice of Privacy Practices, for your convenience.

Notice of Privacy Practices
Please print or download for your own records


Would you like to request a donation to your cause? We love to help support many of the activities and causes that our patients are active in. We are so proud of the many diverse organizations and activities represented among our patients!

If you participate in an activity that you would like our practice to consider supporting, please fill out the form below. Please be aware that because we receive so many requests each year:

  • Requests must be made by a current patient in active treatment at our office.
  • Requests must be made by the person participating in the fundraiser.
  • Requests must be made via our request form (separate documentation can be appended if desired).
  • Priority is given to academic and health-related fundraisers targeting the adolescent age group.
  • Donation requests are due by the 15th of each month, and will be reviewed once a month. Notifications by mail will be sent out by the end of each month.

If your request meets these criteria, please fill out the Application for Donation form. Our committee will review applications and notify you of their decision. Thank you!

Application for Donation
Please print a copy, fill out, and bring to our office, or fax to 218-236-0719.