Forms
Thank you for choosing Eastern Iowa Health Center for your healthcare needs. Below are forms you may need to fill out in order for us to serve you best.
Please call us at 319.730.7300 with any questions.
- Dental Health Questionnaire
- Dental Center Patient Registration Form
- Annual Financial Assistance Application
- Self-Declaration Form Sliding Fee Discount Program
- Health Records Release of Information
- Consent to Treat Minor in Parental Absence Form
Health Record Apps
WHAT OUR PATIENTS ARE SAYING
"Dr. Livermore took time to really listen to me. It feels so good to have a doctor that cares." - Jenny
CONNECT WITH US
- 319.730.7300 | PhoneAssistance available 24/7
- 319.730.7368 | Main Fax
- Send Email
- Get Directions
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Eastern Iowa Health Center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. Deeming applicable to malpractice liability coverage only.