If you want us to call you to schedule a consultation, please email your contact information to NewPatient@painchicago.com or complete the following form. We will make every effort to return your call that day and, if we are unable to, we will call before noon the next work day.
Please read and complete forms & policies and bring to your appointment. Please bring your insurance card and a valid photo ID with you also. Thank you.
Forms:
- Patient Demographics
- Signature Sheet
- HIPAA Form
- ARI Form
- Insurance Communications Consent (ICC)
- COVID 19 Consent Form
- Pain Diagram
- Self Pay Policy Form
- New Patient Packet
- MR Release Form
- Curbside Office Visit Instructions
- Benefits Assignment Policy
- ICC (Portal)
- Interventional Procedure Instructions
Policies:
- Notice of Privacy Practices
- Opioid Policy
- Controlled Substance Agreement
- Opioid Consent for Treatment
- Controlled Substance Policy
I want to "Thank You" for controlling my pain. I want to thank you for the opportunity to see my two children graduate college and then go on to achieve their master's degrees. We now live in Texas with our two children and our two grandchildren. We will be moving into our new home in about three weeks.
I had back pain so bad I couldn’t walk. I tried a chiropractor but got no relief. My husband has been using Dr. Glaser for years and suggested I go see him. I went and have never been happier that I did. I am pain free!!!! Also, I’d like to say that the office staff was very good too.
Learn about our 72 Hour Commitment to your pain relief.
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