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 PCI Health History Form
Medical Record Release of Information Authorization
- Sign, date, and completely fill out the Medical Record Release of Information Authorization form. Include your phone number and complete address on your request in the event of any questions regarding the release of your records.
- Submit your signed and COMPLETED Medical Record Release of Information Authorization to the above address, email it to email@example.com , or fax it to (319) 409-8174.
Authorization to Treat a Minor
Medication/Personal Health Record
Bariatric Patient Intake Form
Ear, Nose & Throat / Head & Neck Surgery (includes allergy and audiology)
Sleep Apnea Questionnaire
Vestibular Therapy Patient History Form
Behavioral Health Intake Form - Adult
Behavioral Health Intake Form - Minor
Hematology & Oncology
Hematology & Oncology Questionnaire
Imaging and X-Ray
MRI Screening & Safety Form
Neurology & Sleep Medicine
Sleep Medicine New Patient Form
Neurology Recheck Form
Orthopedics (includes osteoporosis care and podiatry)
Orthopedics Review of Systems
New Patient Form (Coester, Fabiano, Hart, Hill, Lange, Munjal, Nassif, Pape, Paynter, Switzer, White)
Recheck Form (Switzer)
Back Questionnaire (Eck, Coester)
Foot & Ankle Questionnaire (Dempewolf, McBride & Pape)
Hand Questionnaire (Chimenti, Kluesner, Kuo, Novak, Pardubsky & Fagan)
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 Recheck Form
Vein Screening Form