Privacy & Consent
Communication Form/ Financial Policy
Consent for Release
Authorization of Release of Confidential Information
HIPAA Release of Health Information
Notice of Privacy Practices
Physicals
IHSA Physical Form
School Physical Form
DOT Driver Physicial Form
Dieterich Community Medical Center Forms & Applications
Approved Medications for Pregnant Patients
New Patient Information
Dr’s Flynn & Gage Clinic Forms & Applications
Please contact our office if you are interested in becoming a new patient. 217-347-7030
Runde Clinic Forms & Applications
Please contact our office if you are interested in becoming a new patient. 217-857-6481