Patient Forms
We are pleased to offer an online version of our required office forms, to expedite the admissions process for your upcoming office visit and/or pending procedure at the Winchester Endoscopy Center.
Please review and complete the following before your arrival, signing where indicated. Please call us in advance, if you have any questions whatsoever.
RECEIPT OF PRIVACY PRACTICE FORM
Please remember to bring your insurance card and a picture I.D., when you are checking in at our office.
If you are having a procedure, please read your necessary procedure preparation instructions. You will need to pick-up the prep kit in advance at your pharmacy and allocate time for its use. Some simple dietary modification, in the days before your procedure, is needed.
Request for a Copy of Your Medical Records - Obtaining a copy of your medical record is easy. To start your request, simply download, print, complete and sign our record request form and fax or mail the form to our office. Please be sure to sign the form. Unsigned requests cannot be processed. We make every attempt possible to process and fulfill your record request in 5 working days.
Our fax number is (847) 247-0487.
Our mailing address is:
Northshore Center for Gastroenterology
1880 W. Winchester Road, Suite 201
Libertyville, IL 60048