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Forms

Download pre-appointment forms below. You complete electronically and then print, or you can print blank forms and fill them out by hand. Remember to bring completed forms with you to your appointment.

If you do not have Adobe Reader installed, you can visit the Adobe website to download a free version.

General Forms

PDF_Icon.jpg  General PCI Health History Form
PDF_Icon.jpg  Medical Records Release - All requests for copies of medical records must be received in writing. Print a copy of the form. If the patient is a minor (less than 18 years of age), a parent or legal guardian must sign the authorization. This form must be completed, signed, dated and mailed to PCI Health Information Services, 202 10th Street SE, Cedar Rapids, IA 52403 or faxed to (319) 449-3892.
PDF_Icon.jpg
  Authorization to Treat a Minor

PDF_Icon.jpg  Medication/Personal Health Record

Ear, Nose & Throat / Head & Neck Surgery (includes allergy and audiology)

PDF_Icon.jpg  ENT Questionnaire
PDF_Icon.jpg  Sleep Apnea Questionnaire

Hematology & Oncology

PDF_Icon.jpg  Hematology & Oncology Questionnaire

Imaging and X-Ray

PDF_Icon.jpg  MRI Screening & Safety Form

Neurology & Sleep Medicine

PDF_Icon.jpg  Neurology Questionnaire
PDF_Icon.jpg  Sleep Medicine Questionnaire
PDF_Icon.jpg  Neurology Recheck Form

Orthopedics (includes osteoporosis care and podiatry)

PDF_Icon.jpg  Orthopedics Review of Systems 
PDF_Icon.jpg  New Patient Form (Coester, Fabiano, Hart, Hill, Lange, Munjal, Nassif, Pape, Paynter, Switzer, White)
PDF_Icon.jpg  Recheck Form (Switzer)
PDF_Icon.jpg  Back Questionnaire (Eck, Coester)
PDF_Icon.jpg  Foot & Ankle Questionnaire (Dempewolf, Lozier, McBride, and Pape)
PDF_Icon.jpg  Hand Questionnaire (Chimenti, Kluesner, Kuo, Novak, Pardubsky & Fagan)
PDF_Icon.jpg  Bone Health History Form

Patients of Dr. Ekroth, Hill and Pilcher, please complete the General Health History form at the top of this page.

Rheumatology

PDF_Icon.jpg  Rheumatology Questionnaire
PDF_Icon.jpg  Rheumatology Recheck Form

Vascular Surgery

PDF_Icon.jpg  Vein Screening Form

Urology

PDF_Icon.jpg  Urology Questionnaire

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