Patient Forms

You can find electronic patient forms here. At this time, we are only accepting online patients forms due to COVID-19. If you have problems, please call us at 563-289-3249.

Pre-Screening Form

New Patient Registration Form

Medical History Form

Photography Consent

Financial Policy

Privacy Practices Notice and Consent

Healthy Start Questionnaire

All forms and their information are securely transferred and protected by JotForms

LeClaire Family Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

126 South Cody Road

LeClaire, Iowa 52753

Tel: 563-289-3249

Txt: 563-207-3030

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© 2020 by LeClaire Family Dentistry PC.