Dinkelmann Health Center
Dinkelmann Health Center

New Patient Forms

1. New Patient Welcome Sheet - Print and Complete
New Patient Welcome Sheet.pdf
Adobe Acrobat document [64.6 KB]
2. Consultation and Health History - Print and Complete
Consultation and Health History.pdf
Adobe Acrobat document [53.4 KB]
3. List of Medications - Print and Complete
List of Medications-Supplements.pdf
Adobe Acrobat document [41.4 KB]
4. Patient Record of Disclosure - Print and Complete
Patient Record of Disclosures.pdf
Adobe Acrobat document [48.5 KB]
5. New Fee Schedule - Print and Complete
New Fee Schedule.pdf
Adobe Acrobat document [13.7 KB]
6. Privacy Notice - Informational Only
Privacy Notice.pdf
Adobe Acrobat document [59.6 KB]

"The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease" -Thomas Edison

Need an Appointment?

Give us a call at:

+1 618 2542260

Contact Details

Dinkelmann Health Center

21 E Acton Ave

Wood River, IL 62095

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