Below are links to download PDF files of our patient forms. By filling these out ahead of time, it saves you time at the office.

You will need Adobe Acrobat Reader to view these PDF documents. Most copmputers come with it already installed, but if you don't have it, you can download it for free at Adobe's website.

New Patient Information Form

Payment Policy Form

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Release of Records Form

Samuels Care Center 1130 S. Wabash Avenue, Suite 305 Chicago, IL 60605 (312) 212-1159
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