Patient Forms

The forms here are Microsoft Word documents. You may print out any of the forms and fill them out by hand, fill them out online and then print them, or fill them out online and email them back to us. To email them back to us, first save the completed form as a file on your computer, then attach the file to an email and send it to: patientsweil4feet@gmail.com.

If you have any questions, please feel free to contact us at 847-390-7666.

Registration Forms

• Barrington
• Berwyn
• Chicago (Bridgeport)
• Chicago (Swedish Covenant Hospital)
• Chicago (Lincoln Park)
• Des Plaines
• Glenview
• Highland Park
• Lake Forest (Hospital)
• Libertyville
• Park Ridge

Additional Forms

• Medical Records Release Authorization
• Notice of Privacy Practices
• Request for Confidental Communications
• Request for Correction of Healthcare Information
• Restriction Request Form

Des Plaines
1455 Golf Road . Des Plaines, IL 60016
(847) 390-7666 • e-mail • http://www.weil4feet.com