New Patient Forms

Hello and Welcome to the Northern Illinois Eye Clinic!

We are pleased and honored to have you as a patient.  The following forms can be filled out and printed or emailed to us prior to your visit if you desire.  Please click below for a general history questionnaire, our financial policy form, glasses and contacts policy, and HIPAA  forms.

Our email: info@northernillinoiseyeclinic.com

Fax: 847-566-5310

New Patient History Questionnaire (2 pages)

Nuevos Pacientes Historial Medicos (3 paginas)

Patient Financial Terms Agreement (2 pages)

• Glasses and Contact Lens Policy  (1 page)

HIPAA forms

• HIPAA English (2 pages) -no signature required

• HIPAA in Spanish (2 paginas) -no firma necesario

List of Insurances Accepted