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