Policies And Forms

Registration Forms (For New Patients and Well Visit Appointments)

HIPAA (Health Insurance Portability and Accountability Act) Release Form / Spanish (Updated once a year)

Notice of Privacy

Financial Policy

Patient Information

Flu Clinic Consent Form - English

Flu Clinic Consent Form - Spanish


Well Visit Questionnaires and Forms


Miscellaneous Forms

State of Illinois School Physical Form / Spanish (Required for kindergarten, 6th grade, and 9th grade and upon entering a new school or daycare)

IHSA Sports Physical Form (If requested by school upon joining a sports team)

Asthma Control Test (ACT) 4-11 Years / Spanish, Asthma Control Test (ACT) 12-21 Years / Spanish (Required at least once a year for asthma follow up appointments and/or for children diagnosed with asthma coming for a well visit appointment)

Vanderbilt Assessment Scale - Parent and Teacher Forms (Need at least two parent and two teacher forms required for ADD/ADHD initial evaluation appointments)

Medical Records Release (From our office)

Medical Records Release (To our office)

Healow Application and Televisit Guide

Healow (Workflow)

Contact Us

To get in touch with us, give us a call at (847) 548-7337

1170 E Belvidere Rd Ste 106, Grayslake, IL, 60030

Our Location

Find us on the map

Hours of Operation

MORNING SICK CALL/WALK-IN WILL REMAIN CANCELED UNTIL FURTHER NOTICE. SICK VISITS ARE AVAILABLE BY APPOINTMENT ONLY.

*Office is closed between 1-2 PM for lunch.*

Monday:

9:00 AM-5:40 pm

Walk-in 8-9 AM

Tuesday:

9:00 am-5:40 pm

Walk-in 8-9 AM

Wednesday:

9:00 am-5:40 pm

Walk-in 8-9 AM

Thursday:

9:00 am-5:40 pm

Walk-in 8-9 AM

Friday:

9:00 am-5:40 pm

Walk-in 8-9 AM

Saturday:

9:00 am-12:40 pm

Walk-in 8-9 AM

Sunday:

Closed