Disclaimer:  Forms may be mailed or brought to our office prior to an appointment.  It should be emphasized that physicians will not review these forms, medical care will not be provided and an individual is not considered a patient under our treatment until they have had a formal visit in person with one of our doctors in our office.


New Patient Form (Please print and complete this form and bring it to your visit)


SCHOOL/SPORTS PHYSICAL FORMS
Illinois School Physical Form (PDF) (Parent/Guardian to complete top of page 2 only)
   * Lead Screening Questionnaire (PDF) (If child is 6 months-6 years old, please complete Lead Screen with School Physical Form)

IHSA Pre-Participation Examination Form (Sports Physical)  (Parent/Guardian to complete page 1)


MEDICARE ANNUAL WELLNESS VISIT FORMS
Medicare Wellness Exam Form

ADVANCED DIRECTIVE ILLINOIS FORM (OPTIONAL)


OTHER LINKS
NextMD




Plainfield Family Medicine
23836 135th St Plainfield, IL 60544 Phone: 815-254-2403Fax:815-267-8380

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