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Patient Forms

You may access the following forms to assist us with your care. You may complete the following online form, and click the "Submit" button at the bottom or download and print the PDF form. If you use the printable form, please fill it out and bring it to your first appointment.

Online Form

Printable Form

adobe

*These forms require Adobe Acrobat Reader. Click the Adobe logo above to download.

Wells Fargo Health Advantage® Credit Card*

Because your oral health is important to us, we offer the Wells Fargo Health Advantage credit card. You can apply for the card online or at any The Dental Specialists Orthodontic location. With a comprehensive range of financing plans, it gives you budget flexibility to finance treatment or healthcare expenses and pay over time.

With the Wells Fargo Health Advantage® credit card you can:

  • Pay for co-payments, deductibles, and treatment not covered by insurance
  • Start treatment immediately and pay over time with convenient monthly payments
  • Pay for other healthcare expenses at participating providers for you and your family without having to reapply
  • Reserve existing credit cards for household or unplanned expenses
  • Have no annual fees*
    *The Wells Fargo Health Advantage® credit card is issued with approved credit by Wells Fargo Bank, N.A.  For newly opened accounts, the APR for Purchases is 12.99%. If you are charged interest in any billing cycle, the minimum interest charge will be $1.00. This information is accurate as of 02/01/2018 and is subject to change. For current information, call us at 1-800-431-5921.
  • Apply online or at your The Dental Specialists Orthodontics practice
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