Forms

REQUEST AN APPOINTMENT

 
 
 

Forms

Please print and fill out each one of the listed forms below and bring it to your initial appointment. The following forms are PDFs and can be viewed and printed using Adobe Reader.

New Patients age 13 and younger please fill out:

Child Registration and Health History

New Patients age 14 and older please fill out:

Adult Registration

Health History

Financial Policy

Notice of Privacy Practices

Patient Acknowledgement

Get Adobe Reader

PHONE: (888) 896-5964

E-MAIL US

©2009-2011 Cedar Rapids Smile Center

This site was created by Dental 101