Pediatric Patient Forms

You may download and print any of our forms listed below before coming to our office. This will get you out of the waiting room and in to see the doctor a lot quicker! You may bring the completed form to your first visit, fax it to 847.295.1255 before your appointment or scan and e-mail it through the patient portal.

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com.

• New! Telehealth instructions and consent form

New Patient Forms

• New patient questionnaire
• Notice of privacy practices and financial policy
• Vaccine policy
• “In-Network” Insurance Plans 2023

ADD/ADHD Questionnaires

• Parent questionnaire initial evaluation
• Parent questionnaire followup
• Teacher questionnaire initial evaluation
• Teacher questionnaire followup

Mental Health Forms

• SCARED – Child version
• SCARED – Parent version
• SCAARED – Adult anxiety

Patient Care Forms

• Childhood lead risk assessment questionnaire
• 12 month questionnaire
• 18 and 24 month questionnaire
• Well child check (1 month)
• Well child check (2 months)
• Well child check (4 months)
• Well child check (6 months)
• Well child check (9 months)
• Well child check (12 months)
• Well child check (15 months)
• Well child check (18 months)
• Well child check (24 months)
• VFC Program
• VFC Program (spanish)

Administrative Forms

• Authorization for release of PHI
• Authorization to release medical records
• Duplicate form creation charge notice
• School medication authorization form
• Temporary guardianship form