forms

Current patients: We require all active patients to update their Health History and acknowledge our most recent privacy notices every 3 years. If informed by our staff that you are due to complete this, please print, complete, and bring both the "HIPAA Update" and "Health History Update" forms to your child's next appointment. For multiple children, please complete a health history form for each child. Only one HIPAA form is required, as you can list multiple children on that document.

HIPAA Update

Health History Update

Referring Dentists/Dental Offices: Please fill out the "Patient Referral" form and email to our office, at frontdesk@neiapd.com with any available radiographs. Our office will call the referred patient to schedule an appointment. Thank you!

Patient Referral

 

 

Parents of Kindergarteners: Is your child going to be in kindergarten this next academic year? If so, the state of Iowa requires all kindergarteners have a dental exam. You can find the form below.

Kindergarten Screening

 

contact

 

T: 563.382.6259

F: 563.538.0100

info@neiapd.com

 

  
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Kaytie

Dental Assistant

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Zariah

Registered Dental Hygienist