Dr. Klint R. Butler |  Orthodontists | Grand Island & Kearney, NE

Forms

Welcome to our orthodontic office. We look forward to meeting you. Please click the appropriate forms. You may print the forms below, fill them out, and bring them with you to the new patient examination appointment. You may also request that the forms be mailed to you.

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Click the Adobe logo to download.


Child (under 19) patient information form

Adult patient information form

Orthodontic insurance benefits form

HIPAA Privacy Policy & Acknowledgement of Receipt Form

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