The University of Iowa College of Dentistry

Patient Forms

New patients to the College are expected to complete the following forms. For your convenience the following forms can be completed and printed off in advance of your appointment. Please bring these forms with you to your appointment.

• Patient Registration Form (.pdf)
• Registro del Paciente (.pdf)
• Health History Form (.pdf)
• Cuestionario de Salud (.pdf)
• Medications Form (.pdf) **Please bring with health history
• Medicamentos (.pdf) **Please bring with health history
• Patient Treatment Consent/Agreement Form (.pdf)
• Student Clinic Care Agreement Form (.pdf)
• Authorization for Release of Protected Health Information to a Designated Adult (.pdf)

Other important forms:

• Consent for Complete Dentures (.pdf)
• Consentimiento para Dentaduras Completas (.pdf)

If you need your dental records copied, please print off and complete the consent form below, including your signature, and return it to the College of Dentistry.

• Consent to Release Health Information (.pdf) (Copies of Dental Records)
• Central Records Fax Cover Sheet (.pdf)