Patient Forms

What to bring with you to your first visit:

Please bring your current insurance card to every visit.

  • Your driver’s license or state I.D.
  • Current Insurance Card
  • Completed Registration Form
  • Privacy Forms --- Signed
  • Patient History Form
  • Your child's immunization records and growth charts (if transferring from another practice)

Patient Forms

  • Patient Registration [PDF] [Online]
  • Patient Medical History Form [PDF] [Online]
  • Consent to Treat Form (Minor) [PDF] [Online]
  • Notice of Privacy Practices (HIPPA) [PDF] [Online]
  • State of Illinois Certificate of Child Health Examination [PDF] [Online]

Transfer Medical Records

For families transferring care from another practice, please complete the following medical record release to have your records transferred to our office.

  • Authorization to Release Medical Records [PDF] [Online]

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Click here to download it.

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