Patient Registration Forms

Patient Registration Forms

Prior to your visit, you can print, download, and complete the required patient forms below for a smoother check-in. Bring the completed forms to your visit.

• New Patient Registration Form
• Sliding Scale Eligibility
  • AMC Sliding Fee Eligibility Form
  • AMC Income verification
  • List of Documentation Needed for Financial Interview
• Patient Consent
  • Consent of Notice of Privacy Practices Revised
  • Patient Minor Consent Form
  • HIPAA Privacy

BAck to School

In Illinois, students changing schools, entering daycare, kindergarten (or first grade if not previously enrolled in kindergarten), sixth grade, and ninth grade at any Illinois public or private school (including charter schools) must provide proof of physical examination.

If your child needs a school physical, please bring all their vaccination records and any previous lab results to your appointment if you are a new Alivio patient.

• Preparticipation Physical Evaluation Form (for high school students playing competitive sports at their school)
• State of Illinois Certificate of Child Health Examination