Patient Forms

• General Medical History Form

• General Medical History Form

• General Medical History Form

• General Medical History Form

• New Patient History – Knee
• General Medical History Form – For Shoulder and Other Conditions

• Medical History Form
• Return Patient Progress Report

• General Medical History Form

• General Medical History Form

• General Medical History Form

• General Medical History Form

• New Patient – Pediatric
• New Patient – Lumbar
• New Patient – Cervical Spine

• General Medical History Form

• Spine Patient Questionnaire

• General Medical History Form

• General Medical History Form

• General Medical History Form

• General Medical History Form

• General Medical History Form

• Medical History Questionnaire
• Student-Athlete Pre-Participation Consent Form

In the event you need your medical records transferred to another medical facility or for your own personal files, complete the Medical Records Request Form (MOC535).

This paperwork can be returned by mail, by in-person delivery at our Peoria or Pekin office or by fax to (309) 693-3197. In response, your records will be returned to you via email, fax or regular mail. All imaging (Xray/MRI) is provided to you via U.S. Post on a CD due to the file size of the images.

Please note, records are not available for in-person pickup at our office as all requests are processed by our HIPAA compliant Release of Information company, Healthmark Group. Questions regarding your release of information can be directed to 800.659.4035 or status@healthmark-group.com.

A parent or legal guardian is required to accompany any patient under age 18 to their first appointment.

If a parent or legal guardian cannot attend a subsequent appointment, a Permission to Treat a Minor without a Parent or Guardian Present form must be completed, signed and witnessed. This form is to be provided at check-in by the adult accompanying the minor.

If an injury or surgery requires you to take time off from work, please reach out to your company’s human resources department for their necessary forms in advance of your procedure. This paperwork traditionally has sections that need to be filled out by you and your doctor. Please complete your portion of the paperwork before submitting them to our practice.

All paperwork must be accompanied by a completed authorization to release your health care information (Request for Medical Records and Forms Completion Protocol). Also, note that HealthMark Group requires a $30 processing fee for the completion of FMLA/Disability paperwork. All forms are processed by HealthMark Group, our HIPAA Compliant Release of Information company which handles the billing of the fee. Questions regarding your FMLA/Disability paperwork should be directed to HealthMark Group at 972.895.2138 or fmla@healthmark-group.com.

Forms are sent directly to the employer, disability company or to the patient –– electronically, through a secure portal. They are not available for pick up in the office. Completion of forms may take up to 14 days. Please provide the paperwork to our practice in person or via fax to (309) 693-3197.