Forms

If you have scheduled an appointment with us and would like to have your paperwork filled out before the appointment, please call 309-852-5272 and ask which form(s) need to be completed. You are able to email the fillable forms to First Choice Healthcare and they will have it ready for your appointment!

Adult Physical Fillable Form (PDF)- This form is used for Adult Physicals (18+) and Adult New Patients.

Español Físico Adulto (PDF)- Este formulario se utiliza para pacientes adultos (mayores de 18 años) y pacientes adultos nuevos.

Pediatric Questionnaire (PDF)- This form is used for any new pediatric patients. 

Cuestionario Pediátrico Español (PDF)- Este formulario se utiliza para cualquier paciente pediátrico nuevo.

Printable School Physical Form (PDF) Parent/Guardian will need to complete the top portion of back side and sign. 

Printable Sports Physical Form (PDF) Parent/Guardian will need to complete the first 4 pages and sign and student will need to sign. 

TB Waiver (PDF) This form is used children up to age 5. Please fill this form out and bring it in to First Choice Healthcare so that a nurse can sign in. 

Male Annual Form (PDF) This form is used for male annual exams.

Formulario de examen anal masculino (PDF) Este formulario se utiliza para los exámenes anuales masculinos.

Female Annual Form (PDF) This form is used for female annual exams and for well women exams.

Formulario de examen anual femenino (PDF) Este formulario se utiliza para los exámenes anuales femeninos y para los exámenes de mujeres sanas.

If you are needing records to come to or from our office. Please provide use with the Name, address and phone number of the facility. Also we would need a ID emailed with the Release of Information. You are able to fill out the Release of Information and email to First Choice Healthcare and we will handle what needs to be done.

Release of Information (PDF)