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Plaza Family Dental Center
101 East Southridge Road
Marshalltown, IA 50158
507 S County Rd
Toledo, IA 52342
Welcome to Plaza Family Dental Center where our skilled and professional staff is devoted in making
dental care a pleasant experience for adults and children of all ages. We take pride in providing quality
preventive, cosmetic and restorative dentistry to help keep smiles bright.
To help us meet the goal of providing the best personalized dental care for you, the forms listed below
should be completed and returned prior to your appointment/s. The forms can be picked up and
completed in our office or found online at www.plazafamilydentalcenter.com under the “Patient Forms”
heading on our website. For your first visit, please arrive 15 minutes before your scheduled
appointment time or it may take two visits to complete the necessary paperwork and dental services.
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Registration form/s. Provide personal information for the “Responsible Party”, “Patient
Information”, Employment and Insurance Sections. Bring all insurance cards for the insured
along with employer name and address that correspond to group and ID numbers for the
responsible party. Co-payments and any deductibles are due at the time of the visit. A
CareCredit program payment option is available to assist with some treatment plans.
Medical History form. Complete in advance and bring a current list of any medications to the
appointment. Children/Handicapped patients are to be accompanied by a parent/guardian at
all their visits. A parent or guardian will be signing medical histories for the patient.
HIPAA “Acknowledgement of receipt of Notice of Privacy Practices”.
HIPAA privacy “Consent for Release of Protected Health Information” form. Consent form
should list a phone number to contact you and an additional person that we can talk to about
your personal information, insurance, etc. (i.e. husband, wife, family member or other preferred
contact).
To make the most of your time, please return all requested forms to our office prior to your scheduled
day of appointment. You can stop by our office or drop the forms in the mail. Please call us at one of
the phone numbers listed immediately below with any questions or concerns that you may have and we
will be glad to help you.
Main Marshalltown office: (641) 753-3383 or Toledo office: (641) 484-2466
It is our desire to make your visit as comfortable and timely as possible. In order to provide a thorough
examination, please allow at least an hour and 15 minutes for an initial appointment.
We look forward to seeing you and taking care of all your dental needs. Good oral hygiene promotes
overall good health and we are here to assist you.
Sincerely,
Plaza Family Dental Center