Your appointments just got easier.

To make your visits even easier, we’ve added convenient online forms for you to fill out before you arrive. There’s no more rushing to read through lists or fumbling around for health information – you just arrive and let us take care of your smile.

Plus, since it limits paper handling and in-person contact, it’s an effective way of stopping the spread of COVID-19 and protecting your health and safety.

Remember to fill in your information before you visit our office!

Have questions? Call us at 515-278-4366.

Please complete our COVID-19 questionnaire prior to your visit.

For New Patients

Patient Information & Dental History
Medical History Form
Alternate Communication Form
Registration Form
HIPAA, Financial Agreement, Signature & Consent
COVID-19 Questionnaire

For Existing Patients

Medical History Form
Registration Form
HIPAA and Financial Agreement
Signature & Consent
COVID-19 Questionnaire

About

Meet Our Doctor

Testimonials

Dawson Academy Graduate

Our Services

Special Dentistry

Cosmetic Dentistry

Restorative Dentistry

Preventive Dentistry

Orthodontics

Children’s Dentistry

Hours

MON: 9 AM – 4 PM

TUE: 7 AM – 3 PM

WED: 7 AM – 3 PM

THUR: 7 AM – 3 PM

*Convenient before work, lunch hour, and after work appointments available.

4444 Northwest 128th Street Urbandale, IA 50323, United States

Phone: 515-278-4366

Email: [email protected]

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Send Us A Message

We’ll respond to your question shortly!

Healthy Start Patient Form
Doctor's Name:*
Child's Name:*
Age:*
Your Name:*
Relationship to Patient:*
Sleep Disordered Breathing Questionnaire for Children
The initial column should be filled out at first appointment. Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms.

Not Present: 0
Mild: 1-2
Moderate: 3
Pronounced: 4-5
Does your child:
Snore at all?*
Snore infrequently (1 night/week)*
Snore fairly often (2-4 nights/week)*
Snore habitually (5-7 nights/week)*
Have labored, difficult, loud breathing at night*
Have interrupted snoring where breathing stops for 4 or more seconds*
Have stoppage of breathing more than 2 times in an hour*
Hyperactive*
Mouth breathes during day*
Mouth breathes while sleeping*
Frequent headaches in morning*
Allergic symptoms*
Excessive sweating while asleep*
Talks in sleep*
Poor ability in school*
Falls asleep watching TV*
Wakes up at night*
Attention deficit*
Restless sleep*
Grinds teeth*
Frequent throat infections*
Feels sleepy and/or irritable during the day*
Have a hard time listening and often interrupts*
Fidgets with hands or does not sit quietly*
Ever wets the bed*
Bluish color at night or during the day*
Speech Problems*
(If yes, fill out speech questionnaire below)
Was your reason for coming to this doctor for sleep or dental issues:*
Speech Questionnaire
To be filled out only if #27 was indicated above
Please check all that apply to your child
Is it difficult to understand your child's speech*
Difficult to understand over the phone?*
Nasal speech?*
Speech sounds abnormal?*
Others have difficulty understanding speech?*
Gets frustrated when people can’t understand speech?*
Sometimes omits consonants*
Uses M, N, NG instead of P, F, V, S, Z sounds*
Hoarseness*
Lisp*
If taking speech therapy, for how long?*

Send Us A Message

We’ll get back to you with the answers!

Close without sending a message

Hi Urbandale friend! 😀 Have a question? Leave us a message and we’ll get back to you!

Our office is now open with new measures to ensure your safety. Call us today!

Patient Forms

Your appointments just got easier.

Remember to fill in your information before you visit our office!

Have questions? Call us at 515-278-4366.

Please complete our COVID-19 questionnaire prior to your visit.

For New Patients

For Existing Patients

Additional Forms

About

Our Services

Hours

Send Us A Message

Healthy Start Patient Form

Sleep Disordered Breathing Questionnaire for Children

Does your child:

Speech Questionnaire

Please check all that apply to your child

Send Us A Message