Have a great experience? Could things have gone better? Take a minute to tell us about it. Our goal is to continuously improve the service and care we provide for you and your family.
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 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.
Authorization to Treat a Minor
Orthopedics Review of Systems
New Patient Form (Hill)
New Patient Form (Switzer)
Recheck Form (Switzer and Kluesner)
Back Questionnaire (Eck and Coester)
Foot & Ankle Questionnaire (Dempewolf, Lozier, McBride, and Pape)
Hand Questionnaire (Chimenti, Kluesner, Kuo, Novak, Pardubsky and Fagan)
History of Present Illness Questionnaire (Fabiano, Lange, Pape, Paynter, and White)
Joint Questionnaire (Munjal and Nassif)
Knee Questionnaire (Hart)
Shoulder Questionnaire (Coester, Hart, Munjal)
Bone Health History Form
Patients of Dr. Ekroth, Hill and Pilcher, please complete the General Health History form at the top of this page.