Please fill out the form below to the best of your ability. If you have any questions, please contact us at 773-321-2800.
We have implemented a new mobile check-in process. You will receive information when your appointment is booked, but if you’d like to learn about the process ahead of time, please review this summary.
If you are filling this out on behalf of the patient, click here to request an impairment rating or click here to request an IME.
