Patient Forms - Integrative Medicine
Patient Forms for Integrative Medicine
All forms are viewed through Adobe Acrobat Reader.
New Patient Form
Please fill in the New Patient Form online, print it out, and then bring it with you on your first visit to NMPG.
Personal and Family Health History Form:
Please print out the Personal and Family Health History
Chiropractice Medical History Form
Please fill in the Medical History Form online, print it out, and then bring it with you.
Nutrition Consultation Form
Before your first appointment with Judy Fulop, M.S., N.D. the Nutrition Consultation Form is to be completed and received in our office 24 hours prior to your consultation. You can use one of these methods:
- Fax the form to our office: (312) 926-6285
- Mail the form to our office:
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- Northwestern Integrative Medicine
- Avenue Hotel Office Tower
- 150 East Huron Street, Suite 1100
- Chicago, IL. 60611
How to Request Medical Records:
In order to comply with new "Privacy" legislation, beginning January 2002, NMPG will charge our patients a processing fee for copying medical records. The fee will be $20.00 for the first 25 pages and $0.50 per page thereafter. The $20 advance fee and a signed Release of Medical Records form must be sent to your physician's office prior to processing. A check or money order is accepted for medical records. Check payment should be addressed to MD Copy Service. Thank you.
Click on the office you visit for the Medical Records Form: