2127 MIDLANDS CT. # 204 SYCAMORE, IL 60178 PHONE 815 517 1677
Dear patient,
Due to the fact that each insurance company is different and has various coverage
limitations, we need to know if you are here today for your annual examination
(Physical), a problem visit, or a procedure.
Please check all that apply:
☐ Routine Preventative / Wellness Exam
☐ Problem Visit
☐ Procedure
When a problem visit is combined with a preventative exam, I realize this may generate
an additional charge and I may be responsible for a portion of the charges.
Services are billed with diagnoses documented by the provider at the time of your visit.
We cannot change procedure or diagnoses codes once your visit has been completed.
If you have chosen to be tested for an STD or other lab related procedures, please be
advised that there is a possibility you will be responsible for the charges associated with
this screening from lab.
☐ Yes, I want to be tested
☐ No, I do not
Pease remember, our most important concern is your health and wellbeing.
Printed Name: __________________________________________________________
Patient Signature:__________________________________Date:__________________