Midwestern University Linic

Midwestern University ClinicPatient Registration FormPlease PrintPlease check one:NEW PATIENTFOR OFFICE USE ONLYPt Acct #Bill to Acct #PATIENT UPDATEPATIENT INFORMATIONPARENT/GUARDIAN INFORMATION (If Patient is a minor)Patient Name:Name:(Last)Gender: M F(First)Date of Birth:(MI)/(Last)/(First)Gender: (Circle) M F(MI)Date of Birth://Marital Status: M D S WRelationship to Patient:Address:Address:City, State, Zip:City, State, Zip:Please check the box next to the best phone # to reach you during the dayPlease check the box next to the best phone # to reach you during the dayHome phone #:Home phone #:Cell phone #:Cell phone #:Work phone #:Work phone #:Employer Name:Employer Name:Address:Address:Driver’s License #:Email address:Email address:Emergency Contact:Relationship:Phone:Work Phone:How did you hear about us?Referred by:The Federal Government requires we obtain the following information for reporting purposes only.People will not be identified by the following information.1. What is your RACE? A. White B. Asian C. African American D. American Indian/Alaskan Native E. Native HawaiianF. Pacific Islander G. More than one race2. What is your ETHNICITY? A. Hispanic/Latino B. Non-Hispanic/Non Latino3. What is your primary language? A. English B. Spanish C. American Sign Language D. OtherINSURANCE INFORMATIONPlease provide insurance card(s)Primary InsuranceSecondary InsuranceInsurance Company:Insurance Company:ID #:ID #:Group #:Group #:Customer Service #:Customer Service #:Effective Date:Co-pay:Effective Date:Policy Holder:Policy Holder DOB :Co-pay:Policy Holder:Gender: M FPolicy Holder DOB:Relationship to Patient:Relationship to Patient:Policy Holder Employer:Policy Holder Employer:Gender: M FSIGNEDDATE

MIDWESTERN UNIVERSITY MULTISPECIALTY CLINICPatient Name:Date:Patient Date of Birth:Pain ScalePlease identify your level of pain on the scale provided below.Please describe your pain or condition as it is today: inchingConstantStiffnessPain Body MapPlease indicate the location of any and all current pain and/or irritation on the body diagrams below

MIDWESTERN UNIVERSITY MULTISPECIALTY CLINICS3450 Lacey Rd. Downers Grove, IL 60515NOTICE OF SUPERVISED STUDENT, INTERN OR RESIDENTHEALTHCARE PROVIDERS IN VOLVED IN PATIENT CAREMidwestern University Clinic is a multi-specialty outpatient medical clinic dedicated toproviding high quality care to patients. Midwestern University Clinic is affiliated withMidwestern University, a University specializing in medical and health science education at itscampuses located in Glendale, Arizona and Downers Grove, Illinois, with colleges of osteopathicmedicine, pharmacy, health sciences, optometry, and dental medicine. It is our belief thatMidwestern University Clinic’s affiliation with Midwestern University allows our health careproviders to keep up-to-date with the latest treatment, technology and medical innovations,which result in better treatment to our patients.Midwestern University Clinic is also a resource for the training of students, interns and residentsin various health professions. Specifically, Midwestern University Clinic affords students,interns and residents studying various health professionals at the University with the opportunityto participate in the delivery of care to patients as part of their educational experience, under thesupervision of experienced attending physicians. As a result, one or more of the MidwesternUniversity’s students, interns or residents may be involved in your treatment.Any student, intern or resident involved in your care will be supervised by a fully licensedphysician or other licensed healthcare professional and in no case will you be seen exclusivelyby a student, intern or resident. Prior to the beginning of your treatment, any student, intern orresident involved in your care will be introduced and identified to you.You have the right to request that a student, intern or resident not be involved in your treatment.If you would like to make such a request, please inform the Midwestern University Clinic intakestaff member who processes your patient information form and your treating physician prior tobeginning treatment.If you have any questions about the involvement of students, intern or residents in patient care atMidwestern University Clinic, please contact your provider.Patient InitialDate

Midwestern University Clinics630/743-4500 www.mwuclinics.comThe Home DepotiveLacey RoadBright nvesco Inc.sNorthFinley Road355Fry’sElectronics3450 Lacey RoadDowners Grove, IL 60515630 / 743-4500www.mwuclinics.com88Packey Webb Ford31st Street88Main StreetFrom I-88 Take I-88 to I-355 North In 2.3 miles, take the IL-56/Butterfield exit Turn left (west) on IL-56W/Butterfield Road for about 0.3 miles Turn left (south) at Lloyd Ave. Enter Woodcreek Drive Keep left at the fork at Lacey Road and drive for 0.8 miles Your destination will be on your rightAlternative Transportation:DuPage County Senior Services: 800 /713 -7445York Township Senior Ride Program: 630 /620 -2413DrDouble TreeSuitesld RoadHighland Avenuere ekLacey Roadood cFrom I-355 Take I-355 to the IL-56/Butterfield exit Head West on IL-56W/Butterfield Road for about 0.3 miles Turn left (south) at Lloyd Ave. Enter Woodcreek Drive Keep left at the fork at Lacey Road and drive for 0.8 miles Your destination will be on your rightW56Butterfie355Finley RoadDirections to the Midwestern UniversityMultispecialty Clinicat 3450 Lacey Road, Downers Grove, IL 60515Ogden Avenue34MidwesternUniversity

York Township Senior Ride Program: 630/620-2413 630/743-4500 www.mwuclinics.com Midwestern University Clinics 56 355 88 31st Street Ogden Avenue 34 Butterfield Road Finley Road Lacey Road W o o d c r e e k Electronics D r i v e 355 88 The Home Depot Packey Webb Ford Double Tree Suites Midwestern University venue F i n l e y R o a d Midwestern .