319.235.0164
  • 1047 Thorndale Avenue
  • Waterloo, IA 50701

New Patient Form

New Patient Form

Help us get to know you by downloading and filling out our New Patient Form. Simply click on the link below, enter your information and submit the form. Oh, and remember to bring it with you when you come! For a downloadable version you can print and bring to the office with you, please click here.

Patient Information (Confidential)





Responsible Party




Primary Dental Insurance


Secondary Dental Insurance