Streeterville Patient Registration Form
You may download this form in advance and have it completed before you arrive to make your visit a little easier
Illinois State Standard School Form
This is the standard form for schools for Illinois. Some day care facilities and camps also use this form. Please download this form, complete the top of page one and the parent section on page two. Submit all forms with a STAMPED ADDRESSED ENVELOPE as this will help expedite things, especially during the summer months when there is an extremely heavy volume.
This form is to allow your child's immunization to go onto the State Registry
By law, we need to have a signed acknowledgement of receipt of HIPAA Privacy Rules. Please review, print page 4, and bring in a copy of the signed acknowledgement with you.
Records to Send To Streeterville
If you need a form to have records released to us from another physician or medical facility, fill out this form (be sure to sign it) and fax it back to your current medical provider so that may send records to us. Please note that (by law) there may be a charge assessed by your current medical provider for release of records.
Record Release Form
If you need to have records released to another physician, insurance, etc., please fill out this form (be sure to sign it) and fax it back to us at 312/280-1485. Please note that there is a single charge for the preparation, copy, and archiving of records - depending on the amount of records.