Forms

Below are forms for new patients that can be downloaded and completed prior to your first appointment with us.

Patient Registration
CMG Patient Registration v2.pdf
Adobe Acrobat Document 156.9 KB
Medical History
CMG Patient Medical History v2.pdf
Adobe Acrobat Document 173.7 KB

NICHQ Vanderbilt Assessments are used by our providers to help diagnose and monitor patients with ADHD.

Vanderbilt Initial Assessment Questionnaires
Vanderbilt Initial Assessment Parent & T
Adobe Acrobat Document 308.4 KB
Vanderbilt Follow-up Assessment Questionnaires
Vanderbilt Follow-up Assessment Parent &
Adobe Acrobat Document 498.2 KB

A request for release of medical records must be completed and signed before medical records can be transferred.  Below are forms for both requesting records from a previous medical provider to be mailed to our office, as well as a form authorizing CMG to provide your child's medical record to a third party.

Release of Medical Records to CMG
HIPAA Release to CMG.pdf
Adobe Acrobat Document 99.1 KB
Release of Medical Records from CMG
HIPAA Release From CMG.pdf
Adobe Acrobat Document 173.1 KB

P: 847-658-6065

F: 847-658-6136

 

301 N Randall Rd

Lake in the Hills, IL 60156

        Google Maps

 

 PATIENT PORTAL

Masks will be required in our office should McHenry County COVID community levels become HIGH

** BULLETINS **

 

2022 Influenza Vaccine Clinics

 

COVID-19

  

COVID VACCINE SITES

 

09/02/22: Updated bivalent COVID booster vaccines approved for children 5 and up, 2 months from last vaccine.

 

06/19/22: COVID vaccine approved for EUA in kids 6 months and older.

 

Click HERE for more info

 

CMG VACCINATION

POLICY STATEMENT

Open Letter to Parents
VPS 1.1.16.pdf
Adobe Acrobat Document 136.6 KB

IL VACCINATION REQUIREMENTS

Required Vaccines for IL Schools
IL immunization reqirements 2021.pdf
Adobe Acrobat Document 171.3 KB