Kirk Center for Healthy Living
About Us
Visiting Us
Our Staff
Urinary Urgency and Frequency
Pelvic Organ Prolapse
Post-pelvic Surgery
Post-abdominal Surgery
Chronic Constipation
DRA Treatment
Crystal Bed
Patient Resources
Relaxation & Pain Relief
Help Wanted!
Pelvic Health Table

Please fill out the following forms before your first appointment.

 Kirk Center for Healthy Living  Kirk Integrative Physical Therapy (Brandi Kirk)
     Patient Intake Packet
Patient Consent COVID-19
     Patient Intake Packet
Patient Consent COVID-19

You have three options with the Patient Intake Packet and Patient Constent:
  • Fill it out and email it to OR
  • Fill it out and print it OR
  • Print it and fill it out by hand
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 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
Phone: (815) 838-0529 * Fax: (815) 838-0652
Billing Questions: (888) 437-7557
E-mail us at
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