Patient Page



    Dear Patient,

    In order for Chicago pain clinic to best care for your needs, the information on these forms are
    extremely helpful in our ability to diagnose and treat your condition.  The below forms can be
    downloaded  and completed by hand  and returned to us by fax to 773-894-0320.   Please return
    this three forms and official result of any Image study (MRI, CT Scan, X-Ray and etc..) in order
    for us to contact you for an appointment date.



  • Patient 's Pain Questionaire  Form below:
 
           
 pain questionary form       


  • Notice of Privacy Practices (Please read, then print and sign last page):

            HIPA Form


  • Demography form:

       
Demography form

CHICAGO PAIN CLINICS
Phone# 708-344-1234
FAX # 800-525-1686