Page Title

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

to contact you for an appointment date.

pain questionary form

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

HIPA Form

Demography form

CHICAGO PAIN CLINICS

Phone# 708-344-1234

FAX # 800-525-1686