Bloomington: (812) 822-2489
Mitchell: (812) 822-2489
Martinsville: (812) 822-2489

Patient Forms


Please take a minute to fill out the patient information forms before your first appointment: 

If you would prefer to print forms and bring to office click below:

  • Adult Medical History Form PDF
  • Under-18 Medical History Form PDF
  • Dental Records Release Form PDF
  • HIPAA Acknowledgement of Receipt PDF
  • HIPAA Notice of Privacy Practice PDF

If you’re unable to open PDF files, you can get Adobe Reader® for free.

bloomington orthodontic office
(812) 822-24893925 East Hagan Street, Ste 201
Bloomington, IN 47401
mitchell orthodontic office
(812) 822-24891683 Dixie Highway
Mitchell, IN 47446
mitchell orthodontic office
(812) 822-2489509 IN-39 Bypass
Martinsville, IN 46151