Iowa Holistic Dentistry - New Patient Registration Form 18 and over 2025

Address:14111 Douglas Parkway, Suite 103, Urbandale, IA 50323

(515) 276-7800
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

(The following confidential information is for our records only)
ABOUT YOU
Today's Date

MonthDayYear
Date
Name

PrefixFirst NameMiddle NameLast Name
How would you like our staff to address you?
MaleFemale
Birthdate

MonthDayYear
Date
Age
SS #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedDivorcedSeparatedWidowed
Home #

Country CodeArea CodePhone Number
Cell #

Country CodeArea CodePhone Number
Work Phone

Country CodeArea CodePhone Number
Work Ext.
Email
example@example.com
Parent / Guardian Name (If under 18)
Best # for Parent / Guardian
Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us
Previous Dentist
Present Dentist
Last Visit Date

MonthDayYear
Date
IN THE EVENT OF AN EMERGANCY, IS THERE SOMEONE WHO LIVES NEAR YOU THAT WE SHOULD CONTACT?
His / Her Name

First NameLast Name
Relation
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Work #
Please enter a valid phone number.Format: (000) 000-0000.
Home #
Please enter a valid phone number.Format: (000) 000-0000.
PHARMACY
Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone #

Area CodePhone Number
DENTAL INSURANCE
Primary Dental Insurance
Insurance Co. Name
Insurance Co Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone #

Area CodePhone Number
Member #
Group# (Plan, Local or Policy#)
Insured's name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's SS #
Insured's Employer
Insured's Employer Addres

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Dental Insurance
Insurance Co. Name
Insurance Co Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #

Area CodePhone Number
Group# (Plan, Local or Policy#)
Insured's name
Relation
Insured's Birthdate

MonthDayYear
Date
Insured's SS #
Insured's Employer
Insured's Employer Addres

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Rows	Yes/No	If Yes, Please Explain
Do you require any antibiotics prior to dental treatment?
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills or drugs?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Have you ever had Botox/Dermafiller?
Do you suffer from Headaches or Migraines?
Do you grind or clench your teeth?
Do you sleep with a CPАР?

FOR WOMEN:

Rows	Yes
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING:

Rows	Aspirin	Acrylic	Codeine	Latex	Local Anesthetics	Metal	Penicillin	Sulfa Drugs	Other
Yes

If Other, please explain
AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaAnxietyArthritis/GoutArtificial Heart ValveArtificial JointAsperger's SyndromeAsthmaAutism Spectrum Disorder or Sensory Integration DisorderBladder IssuesBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerCerebral PalsyChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDepressionDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaGastroesophageal/Acid Reflux (GERD)Genital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaImmune Deficiency (Any)Irregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteopeniaOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRespiratory DiseaseRenal DialysisRheumatic FeverRheumatismScarlet FeverSexually Transmitted InfectionsShinglesShortness of BreathSickle Cell DiseaseSinus TroubleSleep ApneaSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
NO TO ALL THE ABOVE
Have you ever had any serious illness not listed above?
If Yes, please explain
Comments
PATIENT CONSENT

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Thank you for filling our this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.lowa Holistic Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-515-276-7800. 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-515-276-7800。
SLEEP QUESTIONNAIRE - 18 and older
Name

First NameLast Name
Date

MonthDayYear
Date
Have you ever had a sleep study?
When?
YesNo
YesNo
Rate your overall energy level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is Excellent
Rate your Sleep Quality

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is Excellent
Difficulty falling asleepDifficulty maintaining sleepWould you consider your life stressfulFrequent snoringWaking up gaspingChoking while sleepingFeeling unrefreshed in the morningExcessive daytime sleepinessMigraines or headachesNeck or facial painMemory ProblemsImpotence (Erectile Dysfunction)Nasal Problems, difficulty breathing through your noseMouth BreatherIrritability or mood swingsHigh blood pressureClench/grind your teethOther
*Questionnaire required by the American Dental Association
Please check any of the following you have EVER had or have at present:
Atrial FibrillationOpen Heart SurgeryMitral Valve StenosisHeart BypassAngioplasty/StentEar Lobe CreasesGestational Preeclampsia
MTHFR Genetic VariationChronic Fatigue SyndromeSjogren's SyndromeOrgan TransplantFibromyalgiaLupusMold Induced DiseaseLyme Disease
Dietary SensitivitiesFood Allergies/IntoleranceColon PolypsCeliac DiseaseCrohn's DiseaseChronic Intestinal BloatingIrritable Bowel SyndromeNutritional DeficienciesGastric BypassGut Dysbiosis/SIBO/SIFOChronic Candida
Insulin ResistancePolycystic Ovary DiseaseAbdominal ObesityMetabolic SyndromeAdrenal FatigueHyperthyroidismHypothyroidismHashimoto's Thyroiditis
Panic AttacksInsomniaRestless Leg SyndromePost Traumatic Stress DisorderSchizophreniaBipolar
Peripheral Vascular DiseasePulmonary EmbolismDeep Vein ThrombosisRaynaud's DiseaseThoracic Aortic AneurysmVaricose Veins
Chronic UTlsBladder RefluxLow TestosteroneLow ProgesteroneFrequent Urination
Periodontal DiseaseTongue TieLip TieBurning Mouth SyndromeBad BreathDry Mouth
Retinal Vascular DiseaseCataractsGlasses / Contacts
Cirrhosis of LiverElevated CholesterolGallbladder Issues
Exercise Induced AsthmaChronic BronchitisReactive Airway Disease
Von Willebrand's DiseaseLeiden Factor V DeficiencyThrombocytopenia
PsoriasisLichen PlanusPemphigusEczema
Tubes in EarsChronic Ear InfectionsSevere Hearing ImpairmentHearing Aids
Chronic Nasal Congestion / Sinus CongestionDeviated SeptumSeasonal AllergiesRecurrent Unexplained Hives
Degenerative Disc DiseaseOsteoarthritisEhlers Danlos SyndromeJoint Hypermobility
List ALL Natural / Non-Prescription Supplements you are currently taking: Supplement / Dose / Frequency / Purpose
BloatingCrampingRefluxIndigestion
CURRENT DENTAL STATUS SURVERY

On a scale of 1-10, with 10 being the highest please mark your rating:
How important is your dental health to you?

1

2

3

4

5

6

7

8

9

10

1 is Not Important, 10 is Extremely Important
Where would you rate your current dental health?

1

2

3

4

5

6

7

8

9

10

1 is Bad, 10 is Excellent
What is the most important thing to you about your future dental health?
How do you feel about visits to the dental office (1 - calm, 10-very anxious)

1

2

3

4

5

6

7

8

9

10

1 is Calm, 10 is Very Anxious
How many times a day do you brush?
How many times a day / week do you floss?
Do you use a waterpik?
Have you had your teeth straightened in the past? Yes (when?)
Is there anything else you would like us to know?
Amalgam RemovalOzoneBiocompatibility TestingAirway ExpansionMyofunctional TherapyMaking your smile whiter
If you had three wishes to change your oral and whole body health, what would they be?
1.
2.
3.
YesNo
if Yes, What is their speciality? Please share name:
What do you normally take to resolve aches and pains?
What are your current Vitamin D Levels?
Approx. last date of the report?
How many servings per week are you getting of fish and other healthy omega fatty acids:
How many cups of water do you drink per day:
YesNo
A lot of details, the more the better!The bottom line, don't bother with the details.Small pieces of information at a time so I don't get overwhelmed.
YesNo
HIPAA COMPLIANCE PATIENT CONSENT FORM
Our notice of privacy practlces provides information about how we use or disclose protected health information.

The notice contains a patient's right section describing your rights under the law. You ascertain that by signature that you have reviewed our notice of privacy practices.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare options. We are not required to agree with the restriction, but If we do, we shall honor this agreement. The HIPAA law allows for the use of the information for treatment, payment, or healthcare options.

By signing this form, I understand that:

•    Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

•   The practice reserves the right to change the privacy policy as allowed by law.

•   The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

•   The patient has the right to revoke the consent in writing at any time and all full disclosures will then cease.

•   The practice may condition receipt of treatment upon execution of this consent.

If you would like us to dlscuss your treatment with any member of your family please list below:
Name

First NameLast Name
Relationship
I attest that the above information is correct.
If you do not want to share your information with any other party please leave the above information blank and sign below.
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Patient Signature (Parent or Guardian of Minor)

Clear
APPOINTMENT CONDITIONS
Our part in our relationship is to help you keep your teeth, your part in our relationship is to make sure to keep your appointments. We are asking for your assistance and understanding of our cancellation conditions.

We require a 24 hour notice if you are needing to change or cancel any scheduled appointment. If you are not able to give us a 24 hour notice a fee will occur from your missed appointment.

If your appointment is with a doctor, you will forfeit 10% of the scheduled treatment. Upon rescheduling your appointment, you will owe the 10% that was forfeited upon missing the previous appointment.

If your appointment is with your hygienist, a fee of $50 will be charged to the card on file.

We never want you to rush when brushing your teeth and we do not want to rush with your appointment. If you are 15 minutes late for your appointment you may be asked to reschedule or we may be required to shorten the length of the planned treatment.

We are happy to assist in rescheduling your appointment by calling the office at 515-276-7800

I acknowledge I have read the above terms and conditions.
Name

First NameLast Name
Patient Signature (Parent or Guardian of Minor)

Clear
Date

MonthDayYear
FINANCIAL GUIDELINE
Thank you for choosing our office as your dental health care provider. At Urbandale Smiles we are committed to providing you with the best possible dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment. In order to achieve these goals, we need your assistance and understanding of our payment policy.

Payment is due upon scheduling treatment. We accept payments by cash, check or credit card (MasterCard, Visa, American Express and Discover). We also accept CareCredit, Outside financing is available upon request and approval (Proceed, PatientFi, Cherry, Lending Club and iCredit Works). All card transactions have an additional 3% charge.

If you have dental insurance, we will help you receive your maximum allowable benefits. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. However, please realize:

Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. When our office verifies your insurance and we provide an estimate of benefits for services, your insurance company has a disclaimer that there is no guarantee of benefits. Insurance companies have the liberty to change your benefit structure at any given time without notifying our office. Having dental insurance does not guarantee payment.

We must emphasize that as a dental care provider, our relationship is you, our patient and your family and not with your insurance company. While the filing of the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us. We are here to help you!

If I have insurance by signing below I autorize Plaza Dental Group to submit to my insurance company and allow my dental benefits to be paid directly to my dental office. Some insurance companies may still choose to send payments directly to the patient, in this case you are responsible to communicate that with Plaza Dental Group unless previously discussed.

I acknowledge I have read, understand and agree to the above terms and conditions.
What do you normally take to resolve aches and pains?
What are your current Vitamin D levels?
Patient Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Should be Empty:

Address:14111 Douglas Parkway, Suite 103, Urbandale, IA 50323

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

ABOUT YOU

IN THE EVENT OF AN EMERGANCY, IS THERE SOMEONE WHO LIVES NEAR YOU THAT WE SHOULD CONTACT?

PHARMACY

DENTAL INSURANCE

Primary Dental Insurance

Secondary Dental Insurance

MEDICAL HISTORY

PATIENT CONSENT

SLEEP QUESTIONNAIRE - 18 and older

CURRENT DENTAL STATUS SURVERY

HIPAA COMPLIANCE PATIENT CONSENT FORM

APPOINTMENT CONDITIONS

FINANCIAL GUIDELINE