CLSMA - Your Appointment

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Preparing for your appointment
The practice has recently converted to a new electronic health record system. If you have not been in for an office visit since February 1, 2011, please print and complete the following patient forms and bring them with you to your next office visit.
-OR-
If our staff or your physician has asked you to fill out a specialty form, please print and complete the appropriate forms below and bring them to your visit.

Patient Forms
Please print and complete all four of the following forms and bring them with you to your visit. If you are not having a Complete Physical, it is not necessary to bring the corresponding form.

Patient Registration Form

Financial Agreement

Notice of Privacy Practices

For Complete Physicals

Dermatology Forms

Dermatology New Patient Registration Form

Acne Questionnaire

Hair Loss Questionnaire

Gastroenterology Forms

Gastroenterology New Patient Registration Form

Gastroenterology Return Patient Registration Form

Medical Records Release Forms
To request a release of your medical records to or from Chicago Lake Shore Medical Associates, please fill out one of the following forms and either fax, mail, or deliver it to our office.

Release of Medical Records From CLSMA

Release of Medical Records To CLSMA

Learn more

Have a question? Need an appointment? Call us at 312-926-6000

676 North St. Clair Suite 2300 Chicago, IL 60611