Patient Forms

Please complete each form neatly and to the best of your knowledge.

These forms must be faxed, mailed or hand delivered  to the Danville Polyclinic, Ltd.

These forms will NOT be accepted through e-mail. 

 

 Authorization for Release of Information

Confidential Communication Request

 

MAIL FORMS TO:

Danville Polyclinic, Ltd

ATTN: Medical Records

707 N Logan Avenue

Danville, IL 61832

FAX FORMS TO:

ATTN: Medical Records

(217) 444-4974