Patient Data Information Form
August, 2002
The Family Medical Center of LaGrange is required by law to have
a privacy policy on file. Each patient is required to have a signed form
on file. If you would like to fill this form out in advance and bring it
to your next office visit, simply click the printer icon to be taken to a
printer friendly page that you may print out, complete, sign and return to the
Family Medical Center of LaGrange.
If you do not wish to do this, you will be asked to complete and
sign one of these forms at an office visit in the future.
Thank you for your cooperation in this matter.
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Family Medical Center of LaGrange, Ltd.
5201 S. Willow Springs Road  Suite
300
La Grange, Illinois 60525
(708) 482-8088
This web site is not intended to be
used as a substitute for obtaining medical advice or seeking treatment
from a qualified physician. Visitors to this web site should not rely
on the information contained in it for advice in particular cases.
This site should not be consulted for use during an attack of illness.
If you are having an illness attack, go to an emergency room, or call
your doctor or your local emergency phone number.
This site is designed & maintained
by All Creations INC.
For questions, concerns, or more information, e-mail:
Copyright© 2002 Family Medical
Center of LaGrange.
All rights reserved.
Revised:
November 01, 2006.
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