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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

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 pci@rrsmedical.com , or fax it to (319) 409-8174.

Authorization to Treat a Minor

Medication/Personal Health Record

Bariatric Surgery

Bariatric Patient Intake Form

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

ENT Questionnaire
Sleep Apnea Questionnaire
Vestibular Therapy Patient History Form

Family Medicine

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

Rheumatology Questionnaire
Rheumatology Recheck Form

Vascular Surgery

Vein Screening Form

Urology

Urology Questionnaire

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