Forms for Our Patients

To save time and make the process more convenient, you can fill out several forms at home before your appointment. Just click on the button below, print out a copy of the form on your printer, fill it out and bring it to your appointment.

The forms available are:

  • New Patient and Assignment of Benefits Form and Family History Form. If you’re new to Fox Valley Family Physicians, you’ll need to fill out these forms.
  • Authorization to Disclose Health Information Form.This form authorizes us to disclose your health information to anyone you specify.
  • Current Review of Symptoms Form. This will help the doctors diagnose your illness.
  • School Physical Form. School physicals are required in Illinois for students entering kindergarten, 5th grade and 9th grade. The form is available in Adobe Acrobat format only.

For your convenience, most of the forms are available in two formats: Adobe Acrobat and HTML. Most computers have the Adobe Acrobat Reader software and can read these documents; if you don’t have the software, or aren’t sure if you do, just use the HTML version.

You can get the free Acrobat Reader software by clicking here.

New Patient and Assignment of Benefits Forms
  

Patient Authoriztion to Disclose Form

Authorization to Disclose Health Information Form (HIPAA)

History and Symptoms Forms
  

Medicare Wellness Forms

State School Physical Form

State Sports Physical Form

Minor Permission Form

Parent Verbal Authorization

Narcotics/Controlled Substances Contract

Notice of Privacy Practice