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806 E Washington St., Bloomington, Illinois 61701

Patient Forms

Please review the details below before accessing the Intake Forms!

If you have not set up a date and time for a Virtual Consult to review your case, please do that before you start the Intake Form or Contact Us for more information.


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If you have a Virtual Consultation scheduled and need to return to the Intake form or if you have talked with a team member and need to fill out a secondary Intake Form, please use the link below.

Be sure to have enough time, about 15 minutes, to fill out the intake form.

Each time you access the intake form the site will ask for a one-time passcode that you will receive in a separate email message at that time.

Feel Free to contact us with any questions or technical issues.

Intake Form Link