Bellevue Center for Orthodontics
Commons Professional Center
1200 112th Ave NE, Suite B-200
Bellevue, WA 98004
P: (425) 453-0551
F: (425) 635-0882

New Patient Forms

stock photo of teenage boy with surfboard Please take a minute to print and fill out the patient information form before your first appointment:


We Offer Automatic Payments

You will benefit in the following ways with any method you choose:

  • Convenience – Since payments are due once a month and treatment is scheduled less frequently, you do not have to remember to mail in your payment
  • No Late Fees – With today’s busy schedules, avoid a late fee
  • Save Time and Money – No stamps, no envelopes and no hassle
  • No Additional Cost to You!

To enroll, simply complete and sign the below authorization and return it to our office, or call our Office Manager, Julie, at (425) 453.0551


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