563.355.1853
PLEASE NOTE: YOU WILL BE CALLED TO VERIFY YOUR INFORMATION BEFORE YOUR APPOINTMENT IS SCHEDULED.
DO NOT USE THIS FORM FOR MEDICAL ADVICE OR IMMEDIATE ATTENTION.
This form is not HIPAA compliant and your personal health information is not protected through this inquiry.
We make every effort to respond to these requests promptly, but we do not guarantee same-day response with this form. If you need immediate attention, please call our office at (563) 355-1853. If you are calling or contacting us after normal business hours, our answering service will send all calls promptly to the provider on call and we will return your call as quickly as possible. If you are experiencing a medical emergency, please dial 911.
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If you do not have a PATIENT PORTAL account, please complete the following:
- In the first dropdown below, Select "Add Me To Your Patient Portal"
- Fill in your first and last name, date of birth, phone number, whether you are a current patient (yes/no), and email, and click SUBMIT. Once complete, you will receive an email registration and confirmation. Need help? Call: 563.355.1853
