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

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

VanLaecken Orthodontics is an orthodontist based in Eastern South Dakota. We provide the highest quality of orthodontic and temporal mandibular joint treatments including Invisalign. We are the most experienced Invisalign provider in South Dakota.

Patient Registration Form

DENTAL REWARDS CERTIFICATE

HIPAA Acknowledgement

HIPAA Privacy Act Acknowledgement

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

SUPPLEMENTAL INFORMED Consent Form