807 Broadway St.,

Gillespie, IL 62033-1100

Therese-Polo-MD-LLC-Header twitter logo-blue box Telehealth Consent

New Patient Forms

In order to help parents be prepared for appointments, we supply a number of common medical forms for you to download and print. We encourage you to fill these out at home and bring them with you to your appointment in order to help prevent distraction and save time.

New Patient Packet

If you are a new patient, please print out the New Patient Packet and fill it out. Bring it with you to your first appointment to make it easier to get you taken care of.

IHSA / IESA Pre-Participation Examination Sports

Physical Form

Children and teens who intend to play sports need to have a physical exam. Please print out the Pre-Participation Examination Sports Physical Form and bring it with you to your appointment.

To help make your appointment easier, we provide common medical forms that can be printed.

infant check up check up physical exam

Downloading and printing forms

Our forms are easy to download and print. Simply click the link to download the file, open the downloaded file, and print them on any printer. Once printed, please fill them out and bring with you to your appointment.

physical check up cta-white

Give us a call with any questions or concerns you may have.

 

217-839-3900