Patient Forms

Click on the links below to download form PDFs.

Outpatient Therapy Orientation

Patient Intake Data Sheet

Patient Medical History

Medicare Questionaire

Consent for Medical Treatment

Authorization for Payment Release of Responsibility

HIE Opt-Out Form

Consent For Use and Disclosure of HIV and Genetic Testing Information to Metrochicago Health Information Exchange – English

Elección de MetroChicago HIE – Spanish