Registration Form     ***Bring the completed form to your appointment along with your insurance card.***

Print this form and complete it if you have an upcoming appointment and:
1. will be a new patient to Doran Clinic;
2. have not been seen at Doran Clinic for 3 years; or
3. have had any insurance changes.

Release of Information:  In order to obtain a copy of your medical records or have them sent to another physician or facility, you must complete the release of information in its entirety, sign it, and date it. The boxed section is only required if the specific information listed needs to be released and is applicable in your situation. It is important to list a telephone number where you can be contacted during the day in the event we would have any questions. Please allow 7-10 days for processing.

After you complete the form, you can:
1. bring the form to the clinic;
2. fax the form to 515-239-6950; or
3. mail the form to: Doran Clinic, ATTN: Medical Records Department, 1015 Duff Avenue, Ames, IA 50010

Diet Instructions Prior to Glucose Testing: If your provider has requested Glucose Tolerance Testing you will want to follow these specific instructions prior to your test.

 Application for Employment:  Employment seekers may send an application and/or resume to our office, Attention: Office Manager.  If there are no current openings we will keep your application/resume on file for a period of one (1) year.



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1015 Duff Avenue, Ames, IA 50010