Lincoln Park Institute

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Download PDF Referral Form

If you are a doctor referring a patient, please fill out our referral form to send with patients on their first visit. Download and print the form on the side of the page, or fill out the online form below. If you would like a referral pad, please call (773-327-2400) our office and we will send one over to you right away.

Online Patient Referral Form

Note: If intravenous or general anesthetic is anticipated, do not consume food or water for 6 hours prior to your appointment. Also, please be accompanied by someone who can help you with your transportation needs upon leaving our office.