Patient Forms

Click on the link below to complete the patient forms on your computer. When finished entering information, please click "Submit" at the bottom of the last page. Each form has multiple pages. We will then have you sign the completed forms when you arrive at your scheduled appointment. If you have any questions, please call our dental office in Council Bluffs for assistance. 712.323.3615 Thank you.

At your first visit please let us know if you would like to be signed up to get your future appointments confirmed by text or email for your convenience.

We are a team of highly educated caring professionals committed to improving our patients' overall health. While providing the highest quality dentistry, our team strives to make each patient comfortable and satisfied. Meet the Team

Contact Us


2612 W. Broadway, Council Bluffs, IA 51501 USA
Dr. Gary Smith Dr. Cary Jackson Council Bluffs IA dentists (712) 323-3615 (712) 325-6155 care@smilesofbroadway.com