Patient Forms

New Patients

Welcome to PrairieShore™ Pain Center! To maximize your time with us, please download and complete the forms below and bring these papers with your health insurance card and government-issued photo ID to your initial visit.

If your paperwork is done, please plan to arrive 30 minutes before your scheduled appointment time.

If you are unable to complete your paperwork prior to your appointment, please arrive 60 minutes before your scheduled appointment time in order to finish these forms. Please contact us at (847) 883-0077 if you have any questions.

Download Full Set of New Patient Forms

Download individual forms:

Request For and Authorization to Release Health Information

HIPAA Privacy Rights Request Form

New Patient Intake Form

Patient Registration Form

Opioid Treatment Agreement

Financial Agreement Form


Existing Patients

Welcome back to PrairieShore Pain Center! Please print out and fill in the follow up intake form ahead of time so that we may maximize your time with us. Download Existing Patient Forms below:

Follow Up Intake Form


Note

All our forms are provided in Portable Document Format (PDF). To view and utilize a PDF file () you may need to download the free Adobe Reader software.

Portable Document Format (PDF) is a file format used to present and exchange documents reliably, independent of software, hardware, or operating system. Invented by Adobe, PDF is now an open standard maintained by the International Organization for Standardization (ISO).


At PrairieShore™ Pain Center, our goal is to relieve your pain and improve your quality of life. If your primary physician has advised you to see a specialist for your pain, turn to us for help. To schedule your appointment, please contact us here or give us a call at (847) 883-0077.