Patient Forms

General Forms

• Authorization for JCHL to Request Records
• Consent to Treat
• Acknowledgement of Privacy Practices/Designation of who can receive medical information
• Adolescent Patient Portal Proxy Consent

Service Line Forms

Behavioral Health:

• Adult Intake Assessment Form
• Child Intake Assessment Form

Fairbury Family Medicine Clinic

DOT Forms

• Commercial driver medical examiners certificate
• Commercial driver medical report form
• DOT – vision form
• DOT – insulin dependent form
• DOT – Medication form
• DOT – Non-insulin form

Family Medicine Forms

• School/Sports Physical Form