Patient forms

Dr. Karam requests that you bring ALL bottles of medications, vitamins and supplements to EVERY office visit.

Download patient forms here. Please print these out and complete prior to your office visit:

1. Patient Registration Form

2. Patient Registration Form page 2

3. Medical History Form (4 pages)

4. Medication List

5. Payment Policy

6. HIPAA Acknowledgement Form

7. Patient Portal Informed Consent

8. Policies and Procedures

9. Record Transfer Request
(This form can be used to request copies of your prior results and office visit notes from a previous primary care doctor or a current specialist.)

Please read over the following documents prior to your appointment with Dr. Karam. It is NOT necessary to print these out or to bring with for your visit.

Electronic Health Record Letter

Notice of Privacy Practices

Consent Form Definitions

Annual Letter 2018

Additional Links:

HIPAA Privacy Information
The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.

Illinois Department of Public Health
Forms available in English and Spanish include:
Statement of Illinois Law on Advance Directives
Living Will Declaration Form
Declaration for Mental Health Treatment Form
Power of Attorney for Health Care, Illinois Statutory Short Form
IDPH Uniform Do Not Resuscitate (DNR) Advance Directive
IDPH Uniform DNR Advance Directive Guidance for Individuals

Application for a Driver's License Handicap Parking Permit Sticker

Illinois Advanced Directives