HOW TO BECOME A PATIENT
Welcome to the Couri Center and thank you for choosing us!
- Please confirm that the Couri Center is in your insurance network. We are in many insurance plans, but since we are a private practice and not owned by any of the hospitals, it is always a good idea to confirm.
- Please complete the following patient forms, as applicable, and return to us.
As soon as we receive your paperwork and enter your information into our system, we will contact you right away to schedule an appointment.
We look forward to partnering in your healthcare! Please call 309-692-6838 with additional questions or click below.
Patient Forms
New Patients - Women
- Patient Information Form (Required for all new patients)
- Gynecologic Questionnaire (Required for all new patients)
- Medical Release Form
- Insurance Card (copy front/back) please mail or email a copy to info@couricenter.com
- Care of Unaccompanied Minor: Consent to Treat
New Patients - Men
- Male Medical Forms
- Insurance Card (copy front/back) please mail or email a copy to info@couricenter.com
Please complete and email forms to: info@couricenter.com.
It is critical we receive these forms at least 24 hours prior to your appointment time.
Instructions
Print forms and fill in by hand.
- Scan completed documents and email to info@couricenter.com.
OR
Complete forms online as .pdf.
- Please open each form and save it on your computer, preferably add your last name to the file name while saving.
- Open the saved documents and complete each fill-in form.
- Save completed documents.
- Email completed documents as attachments to: info@couricenter.com
CANCELLATION POLICY
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $40. Please help us serve you better by keeping scheduled appointments.