Algonquin 847-854-5900
Lake Barrington 847-382-8900
Schaumburg 847-895-2900
New Patient Information
General Information
New Patient Forms
New Patient Forms
Please download and fill out ALL forms and sign where necessary.
For the New Patient Questionnaire, fill out one form per child.
New Patient Information
(PDF)
Office Financial Policies
(PDF)
Parental Consent for Emergency Treatment
(PDF)
New Patient Questionnaire 0-2yrs of age (1 for each child)
(PDF)
New Patient Questionnaire 3-12yrs of age (1 for each child)
(PDF)
Notice of Privacy Practices
(PDF)
Consent for Release of Medical Records
(PDF)
GAPS Implementation Materials
These forms were designed to support the implementation of the Guidelines for Adolescent Preventive Services (GAPS)
Optional
Younger Adolescent Questionnaire
(PDF)
Middle/Older Adolescent Questionnaire
(PDF)
Parent/Guardian of Adolescent Questionnaire
(PDF)
School Physical Forms
Sports physical form
Illinois childcare physical form
(PDF)
Illinois school physical form
(PDF)
©Children & Teens Medical Center 2006
