Patient Forms

New Patient Forms:

We are excited to welcome you in to our practice and cannot wait to meet you!  Please take a moment to complete our New Patient Information Form and HIPAA Privacy Consent Form prior to your first visit. (Please complete both forms)

New Patient Information Form
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HIPAA Consent Form
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Other helpful forms:

Retainer Options Form

(Review retainer information, review options for additional sets of retainers, and select your preference)

Fill Online


For your convenience, we offer electronic and automatic payment options from a checking/savings account or through a debit/credit/FSA/HSA card. Download the appropriate form here:

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

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Derby Orthodontics

  • Derby Orthodontics - 2701 N. Rock Rd., Suite 600, Derby, KS 67037 Phone: (316) 719-1900 Fax: (316) 252-8105