Randy Poole, DDS
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319-337-2193

15 N. Van Buren St. Iowa City, IA 52245

Patient Forms

To speed the check-in process, you may complete your forms prior to your visit to Dr. Poole's office.

If you do not complete these forms in advance, please plan to arrive 15 minutes prior to your appointment time.

(All forms are PDF files – Acrobat required to view and print forms)

Patient Information and History

Please print out this form and fill out all fields on both pages, then bring it with you when you come in for your first appointment.

view & print

Patient Claim Form

Please print out this form and fill out the highlighted fields only, then bring it with you when you come in for your first appointment.

view & print

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