New patients
New Patient Intake
Health history and information for your first appointment. Tell us about your concerns and the questions you want to discuss.
Word document · DOCX · 24 KB
Download form
Patient forms
Patient Forms
for Our Freeport Clinic
Complete your paperwork at home before your appointment. Download the forms you need, print and fill them in, then bring them to your appointment or email or fax them to us.
- Download your forms
- Complete at home
- Bring, email, or fax
Your paperwork
Download New Patient
and SHAPE Forms
New patient intake and HIPAA paperwork are required for new patients. The SHAPE intake is for patients starting that program.
New patients
HIPAA Notice & Consent
Read and complete the clinic privacy notice and consent document as part of your new patient paperwork.
Word document · DOCX · 14 KB
Download formSHAPE program
SHAPE ReClaimed Intake
Complete this intake if you are starting the SHAPE ReClaimed program. Ask our team if you are unsure which paperwork you need.
Word document · DOCX · 76 KB
Download formBring your forms, or email or fax them to us
Email completed forms to [email protected] or fax them to (815) 233-3379.
Before you arrive
How to Complete
and Return Your Forms
- 01
Download & print
Choose the documents for your visit and open them in an app that supports Word files.
- 02
Complete your paperwork
Fill in the requested information. Note any questions you would like to ask our team.
- 03
Bring, email, or fax
Bring the completed forms to your appointment, email them to [email protected], or fax them to (815) 233-3379.
Common questions
Patient
Paperwork Questions
Call our team if you have trouble opening a document or need help before your appointment.
Call (815) 232-4217Which forms should I complete?
New patients should complete the New Patient Intake and HIPAA Notice & Consent documents. If you are starting SHAPE ReClaimed, complete the SHAPE intake too. Call our team if you need help choosing the forms.
How do I return my completed forms?
Bring your completed forms to your appointment, email them to [email protected], or fax them to (815) 233-3379. Keep a copy for your records and call if you want to confirm that we received them.
What format are the downloads?
The forms are Word documents (.docx). Open them in a compatible document app, then print and complete them. If you have trouble opening a file, call our team for help.
What if I cannot print or complete a form?
Call (815) 232-4217 before your visit. Our team can explain how to get the paperwork and help with questions about completing it.
Talk with our team
Get Help With
Your Patient Forms
Contact our clinic for appointment and paperwork questions.