Forms

New Patient Paperwork

Please select the physician you have scheduled your appointment with from the list below and complete all forms prior to your appointment. Please give the receptionist your completed forms upon checking in for your appointment. Completing these forms prior to your appointment helps expedite the check-in process.

• Steven Antonini, M.D. New Patient Paperwork
• Michael DeMaertelaere, D.O. New Patient Paperwork
• Aileen Donausky, M.D. New Patient Paperwork
• Orest Horodysky, M.D. New Patient Paperwork
• Julie Limon, M.D. New Patient Paperwork
• Christopher Udovich, M.D. Patient Paperwork

Along with your completed paperwork, please bring the following items to your initial appointment: a current health insurance card, photo identification, a list of any medications that you are taking, and a copy of your immunization/shot record.

Pediatric Forms

• 9 Month Questionnaire for Pediatrics
• 18 Month Questionnaire for Pediatrics
• 24 Month Questionnaire for Pediatrics
• Asthma Control Test Ages 4-11
• Asthma Control Test Ages 12 and Up
• Childhood Lead Screening IDPH
• School Physical Form DHS
• Sports Physical Form IHSA

Adult Forms

• Medicare Annual Wellness Visit Questionnaire
• Humana Medicare Annual Wellness Assessment
• Asthma Control Test

Additional Forms

• Request for Medical Records
• Medical Power of Attorney