New Patient Forms

1870 West Winchester Road, Suite 246, Libertyville, IL 60048

Fax (847) 816-9724

Demographics

Medical History (please check all that apply)

Social History

Surgical History

I have answered all of the questions to the best of my knowledge. I will notify the doctor of any changes in my health or medications. I authorize the release by Dr. Kwiecinski/Dr. Surowiec of my medical records to other pertinent physicians/healthcare providers. I authorize the payment of medical benefits to Dr. Kwiecinski/Dr. Surowiec. In addition, I also request payment of government benefits to Dr. Kwiecinski/Dr. Surowiec who accept assignment for services provided. I verify that I have provided all available forms of insurance. I acknowledge that I am responsible for all charges incurred for products and services provided to me.

Our office reserves the right to charge a $25.00 fee for appointments that were missed or not cancelled within 24 hours of the appointment time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Request For Confidential Communications

I request that all communication to me by Dr. Kwiecinski and/or Dr. Surowiec and their staff be handled in the following manner:

I acknowledge that I was provided access to a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and I understand the information contained within.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.