Patient Forms

Waiting Room

We welcome you to the office of Dr. Michele Couri – The Couri Center for Gynecology and Integrative Women’s Health. Thank you for choosing us.  We look forward to providing you with the highest quality of care and trust

Patient Forms

To allow us to better serve you, and expedite your check-in process, we need the following information 2-weeks prior to your appointment.

If you have an Integrative or Food Sensitivity appointment:

We have included these forms above for you to fill out at your convenience at home.  Please complete and return all forms and a copy of your insurance card via email:

or mail to:

The Couri Center

6708 North Knoxville Avenue, Suite 1

Peoria, Illinois 61614


Unfortunately, if we do not receive these forms two weeks prior to your appointment, we will ask you to reschedule. We take pride in providing the utmost in compassionate and comprehensive gynecologic care and your paperwork helps us do just that right from the start.

Thank you, we look forward to meeting you!


If you are a NEW PATIENT: Please arrive 15 minutes early.


Please complete the above (3) forms as follows:

  1. Print all (3) forms and fill in by hand. Then either:
  1. Mail to our office.  Or
  2. Scan completed documents and email to


  1. Complete forms online as .pdf:
  1. Please open each form and save it on your computer, preferably add your last name to the file name while saving.
  2. Open the saved documents and complete each fill-in form.
  3. Save completed documents.
  4. Email completed documents as attachments to:

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.