About Us Physicians Diagnosis and Treatment Testing Audiology Testing Chicago Dizziness and Hearing Home Physical therapy
  Address
645 N Michigan
Suite 410
Chicago IL
USA 60611
  Phone
312-274-0197
  Fax
312-376-8707
  Email  

Medical Forms for New Patients

We will ask you to fill out a questionnaire, and supply insurance information. It is recommended that you bring it in yourself already filled out. This will save some time. Please fill out one of the following questionnaires.

If you would like to have information sent to us from your doctor, please fill out the records release form (pdf format) and send it to the doctors.

We also greatly appreciate bringing in any available records especially including CD's of MRI or CT scans of the brain or neck. We will load these and return them to you.

Legal disclosures and consent to care (pdf format)

(We will ask you to sign to acknowledge that you read and consent at the time of your first visit. Copies are also available in the office)

 

Miscellaneous

The symptom diary form can be downloaded to help organize the results of treatment. This is mainly used for people who have already been seen once and who are undergoing treatment trials.

More information about what to expect at your visit can be found at the Appointment page.