In order for us to provide the best care possible and to avoid any delays during your appointment, we ask for you to print out and fill out the new patient questionnaire below prior to your appointment. If you have any questions about any items on the form or need help filling it out, call us at 708-745-9900 for help.


New Patient Forms

Welcome

On behalf of the physicians and staff of Alpha Med Physicians Group, we would like to welcome you to
our practice. We realize that you have choices, and we appreciate that you have entrusted us with your
care. We will strive to make your visit as pleasant and comfortable as possible. We have included a New
Patient Packet to streamline the registration process. Please complete the following enclosed forms:

*Patient Information Form: Provides us with up-to-date information.

*HIPAA Authorization Form: Indicates to whom we may release your medical information and the
method of contact.

*HIPAA Consent Forms: Acknowledges that we have provided you with a copy of our Notice of
Privacy Practices Form.

*Pharmacy Consent Form: We prefer to e-prescribe your prescriptions for fast and accurate dispensing.
This form allows us to electronically submit prescriptions to your pharmacy of choice.

In addition to the forms above, please bring the following to your appointment:

*All pertinent test results provided by your doctor.

*Current list of all medications, including over-the-counter and herbal supplements. You may bring the
medication bottles instead of a list, if you prefer.

*List of questions or concerns that you would like to discuss with the doctor.

*Most recent insurance and prescription cards along with a photo I.D., and a referral from your primary
care physician when necessary.

We welcome and encourage family and friends to accompany you to your visit. For the safety of our
patients and staff, Alpha Med Physicians Group asks that you try to limit visitors to one or two people.

Please note that we do not allow children in the Lab. Children must remain in the Lobby area under the
supervision of a parent or guardian at all times.

If there is anything that we can do to make your visit more pleasant, or if you need assistance or
clarification, please do not hesitate to contact any of our staff members.

 
Thank you for choosing Alpha Med Physicians Group.