Patient Registration Form

Please download the form below and complete all fields. Email the completed form to  info@vanlaeckenorthodontics.com or mail the completed form to the corresponding office location to register as a patient. 


Aberdeen Office  |  631 S. Roosevelt St., Aberdeen, SD 57401  |  Phone: 605-226-3120

Watertown Office  |  600 4th St. N.E., Suite 103, Watertown, SD 57201  |  Phone: 605-882-1500

Milbank Office  |  102 W. 4th Ave., Suite 2, Milbank, SD 57252  |  Phone: 605-432-5011

Brookings Office  |  604 Medary Ave. S., Brookings, SD 57006  |  Phone: 605-692-7063

Download Patient Registration Form

DENTAL REWARDS CERTIFICATE

Please download the document below, and complete to be entered into a Smile Rewards Program prize drawing. Email the completed form to info@vanlaeckenorthodontics.com or mail the completed form to the corresponding office location.

HIPAA Acknowledgement

Download the document below, and complete to acknowledge the HIPAA Privacy Act and VanLaecken Orthodontics' Privacy Notice. Email the completed form to info@vanlaeckenorthodontics.com or mail the completed form to the corresponding office location. 


You may also complete the digital form below to acknowledge our Privacy Notice.

HIPAA Privacy Act Acknowledgement

I hereby acknowledge that I have received and reviewed a copy of VanLaecken Orthodontics Privacy Notice. (A copy is available for your viewing on our website.)

Please Complete this Form to Let Us Know You Have Received and Reviewed VanLaecken Orthodontics' Privacy Notice

You may refuse to sign this acknowledgement.

SUPPLEMENTAL INFORMED Consent Form

Download the document below, and complete to consent to receive orthodontic treatment during the COVID-19 era. Email the completed form to info@vanlaeckenorthodontics.com or mail the completed form to the corresponding office location. 


You may also complete the digital form here.