Fairfield, OH (513) 829-4400
Cincinnati, OH (513) 923-1800
West Chester, OH (513) 777-9040
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Patient Forms

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Patient Forms at Nelson R. Diers OrthodonticsTo save you time at your initial visit, we have provided the necessary new patient forms below. Simply download, print and complete the forms (PDF), and bring to your appointment.

All patients should complete a new patient form, the HIPPA privacy policy and a sleep assessment. Adults or children, if you are experiencing any jaw problems, such as pain, noise in the joint, or headaches, please complete the TMJ form as well.

Adults—Please complete a new patient form and sleep form.

Please complete this adult new patient form.
Please complete this sleep form. (Age 16 & over.)

Children—Please complete a new patient form and sleep form.

Please complete this child new patient form.
Please complete this sleep form. (Age 15 & under.)

If you have any TMJ symptoms, please complete the TMJ form.

This is theTMJ form.

Our two page printable HIPPA privacy policy & verification page can be found here.
Our Records Release page can be found here.

If you need any assistance, or have any questions, please do not hesitate to call our office at (513) 829-4400.

Our Mission


To constantly improve the orthodontic experience with superior innovative service.

To positively affect our patients lives with an honest, trusting, and considerate orthodontic team.

To grow together in mind, heart, and spirit with superior management, emphasizing communication, encouragement, kindness, and patience.


Our Hours


Mon 9am–6pm
Tue 10am–7pm
Wed 8am–5pm
Thr 8am–5pm
Fri 8am–12pm
Sat 8am–12pm




Nelson R. Diers, DDS | www.diersorthodontics.com | (513) 829-4400
1251 Nilles Rd, Suite 14 Fairfield, OH, 45014
Copyright © 2016-2017 Nelson R. Diers, DDS and WEO MEDIA. All rights reserved.  Sitemap | Links