Kirk Center for Healthy Living
About Us
Visiting Us
Our Staff
Specialties
Incontinence
C-section
Post-prostatectomy
Urinary Urgency and Frequency
Nocturia
Pelvic Organ Prolapse
Post-pelvic Surgery
Post-abdominal Surgery
Chronic Constipation
Dyspareunia
Crystal Bed
Patient Education
Additional Services
Reflexology
Yoga
Help Wanted!
Pelvic Health Table

Forms
Please fill out the following forms before your first appointment.

 Kirk Center for Healthy Living  Kirk Integrative Physical Therapy (Brandi Kirk)
  
     Patient Intake
Patient Services Agreement
Documentation of Current Medications
Credit Card Authorization
Cancellation and No-show Policy
     Patient Intake
Patient Services Agreement
Documentation of Current Medications
Credit Card Authorization
Cancellation and No-show Policy

Anyone whose primary complaint involves bowel, bladder or prolaspe issues: Bowel/Bladder/Prolapse Questionnaire
Females whose primary complaint is pain: Female Pain Questionnaire
Males whose primary complaint is pain: Male Pain Questionnaire

You have three options with the Patient Intake form (all other forms require a signature):
  • Fill it out and email it to forms@kc4hl.com OR
  • Fill it out and print it OR
  • Print it and fill it out by hand
The other three forms must be printed, as your signature is required on those forms.

If you would like to fill in the Patient Intake form via your computer, when the form opens in Adobe Reader, click just to the right of the label NAME: and simply type on the line. Then use your tab button, or your mouse, to move from line to line. Once you have completed the form, print the completed form and bring it with you on your first visit. Or, you can save the completed form and email it to forms@kc4hl.com at least 24 hours before your appointment.

If you prefer not to fill in the form using your computer, simply print it out, fill it out by hand and then bring it with you on your first visit.

You must have Adobe Reader to open this form. If you do not have Adobe Reader, click on the Adobe Reader link on the left, below the menus, to install it.

If you have any questions please call us at (815) 838-0529.
Adobe Reader is required to view forms
   
16618 W 159th Street, Suite 402, Lockport, IL 60441  |  5851 W 95th Street, Suite 300, Oak Lawn, IL 60453
Phone: (815) 838-0529 * Fax: (815) 838-0652
Billing Questions: (708) 424-6334
E-mail us at info@kc4hl.com
© 2005-2017 Kirk Center for Healthy Living - All Rights Reserved