Your First Appointment

You can arrange your first appointment easily and quickly.

Call (630) 632-4208 or email at [email protected], leave your name (please spell it as well to ensure clarity), telephone number where you are most readily available, and some possible times to best return your call.

Most calls are returned within 4 hours. Upon call back, you will be asked a few simple questions and given your first appointment.

A diagram of the highlands whole person model.

Client Registration

Name(Required)

Phone(Required)

Email(Required)

Date

Patient's Last Name (Must be Legal Name)

Patient First Name

Address

Sex

Male

Female

Age

Date of Birth

Marital Status

Whom May We Thank for Referring You?

In Case of Emergency, Whom Should Be Notified?

Phone

Purpose of Visit

Known Medical Problems

Church or Religious Affiliation

Person Responsible for Payment of This Account (Guarantor)

Guarantor Name

Relationship to Patient

Address

Phone

Occupation

Phone

This field is for validation purposes and should be left unchanged.