M.Chavez MD, SC
2222 W. Division St, Suite 205, Wicker Park | (773) 227-3303


This page will help you save time at the office by allowing you to pre-register prior to your first office visit. Pre-registration will permit our staff to verify your information so that you can spend more time discussing your health and concerns with your physician. Your email will allow us to enroll you in Patient Fusion, giving you instant 24-hour access to your health information online, including progress notes, labs, and the clinic schedule.

Demographic Forms

Please complete the following Online Forms prior to your initial visit. 

Demographic Information (pdf)

Notice of Privacy Practices Acknowledgement (pdf)

Assignment of Benefits Form (pdf)

Medical Forms

Please complete these medical forms prior to your first visit. They will help your physician with the management of your health.

Medical History (pdf)

Preventive Health Questionnaire (pdf)

Procedure Questionnaire (pdf)

Telehealth Consent Form (pdf)

Advanced Directives

These two forms will help plan for your continued care in case you are unable to make the decision yourself. Please review these downloadable forms with your family and discuss with your physician.

Living Will (pdf)

Healthcare Power of Attorney (pdf)