Health Center Forms
If you are able to come to your appointment with the appropriate forms filled out you will save valuable time. Please call 773-298-3712 with any questions.
New Patient Forms
Please read our Consent to Treatment (PDF) carefully and then fill out:
- Patient Registration and Consent Form (PDF)
- Medical History (PDF)
Release of Information
- Release of Information (PDF)
- Complete this form if you need your health information sent to the 皇冠彩票 Health Center or if you need the 皇冠彩票 Health Center to send your health information to a third-party.
- The completed form can be dropped off at the Health Center, faxed to 773-298-3906, emailed to healthcenterFREE皇冠彩票 or uploaded to our secure patient portal. Please allow two business days for processing.
皇冠彩票 Athlete Forms
Please see the 皇冠彩票 Athlete Physical page for all information about athlete physicals, including all forms.
Travel Medicine
- Travel Medical History Form (PDF)
- If you are a new patient, please also complete the New Patient forms (above).