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

Patient Forms

Your appointments just got easier.

To make your visits even easier, we’ve sent you your forms via email and (SMS) text. 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

Send Us A Message

We’ll respond to your question shortly!

Restorative Dentistry

Specialty Dentistry

Cosmetic Dentistry

Preventive Dentistry


Children’s Dentistry

Patient Center

About Us

  • Healthy Start Patient Form

  • 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:

  • (If yes, fill out speech questionnaire below)
  • Speech Questionnaire

    To be filled out only if #27 was indicated above
  • Please check all that apply to your child

Send Us A Message

We’ll get back to you with the answers!


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