Patient Forms

Your Home for Orthopaedics

At Midwest Orthopaedic Center, we’re always working to make your experience as effortless as possible.

Below you’ll find pre-visit forms, listed under your doctor’s name or the service you’re seeking. Please download, print and fill out the appropriate paperwork. At your first appointment, provide the form(s) at check-in. This will streamline your new-patient process and help your doctor, nurses and/or physical therapists best take care of you.

If you have any questions, please reach out to us using the contact information provided below. Thanks for putting your trust in your home for orthopaedics. We look forward to helping you.

In the event you need your medical records transferred to another medical facility or for your own personal files, complete the Medical Records Request Forms (MOC534 and 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 320.373.0007

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 320.373.0007.

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.

Meet Our Patients

I used the walk-in clinic and was helped immediately: x-ray, exam and injection were completed in less than an hour. Very excellent experience with Dr. Lilly and Theresa R. Would highly recommend them!!

An acute trauma patient

At Midwest Orthopaedic Center, I trust Dr. Gibbons completely with my care. He's the very best there is.

A patient of Dr. Gibbons

Dr. Brad Roberts is a provider you actually look forward to seeing. He takes time to know you as a patient, is sympathetic, approachable with questions, and overall seems a great person.

A Patient of Dr. Roberts

Alicia Ruemelin Midwest Orthopaedic Patient
Dr. Bell helped me stay on top of my back problems — always with quick, attentive service. He even got a second opinion from another specialist within the practice. Everything I need is all under one roof.

Alicia Ruemelin

A back patient who loves to play and coach volleyball –– from Morton, IL.

I couldn't sleep at night, I didn't have energy for my kids and I was tired at work. My family doctor referred me to Dr. Mahoney. He was nice, knowledgable and made me feel at ease. After treatment, I feel amazing, like I never had issues.

Jessica Isbell

A carpal tunnel patient who loves to cook –– from Farmington, IL.

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Call Us to Set Up an Appointment

Peoria (309) 691-1400

Pekin (309) 353-4159

Get Hours & Location Info

Midwest Ortho First Walk-In Clinic Hours: M-F 9am-6pm | Sat-Sun 9am-noon