755 Ela Road Lake Zurich IL

Please click on the title below to access the forms listed based on your insurance and fill out prior to your first visit. If you do not fill out forms prior to your visit, please arrive 15 minutes prior to your scheduled appointment to them out in the clinic.  Please also bring the prescription from your referring physician.

Medicare Patients

Download Required Forms

  • Patient Intake Form
  • Medical History Form
  • Medication List
  • Falls Risk Checklist
  • Patient Consent/Stmt. of Financial Responsibility
  • Visual Pain Scale/Body Map

 

Non-Medicare Patients

Download Required Forms

  • Patient Intake Form
  • Medical History Form
  • Patient Consent/Stmt. of Financial Responsibility
  • Visual Pain Scale/Body Map

 

Required Pelvic Forms

For those who primary complaint involves:
Download Bowel, Bladder or Prolapse: fill out Bowel, Bladder, Prolapse Questionnaire (PFDI 20)

Females whose primary complaint is pain:
Download Female Pain Questionnaire (Female NIH)

Males whose primary complaint is pain:
Download Male Pain Questionnaire: (Male NIH)