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
To allow us to better serve you, and expedite your check-in process, we need the following information 2-weeks prior to your appointment.
- Patient Information Form
- Gynecologic Questionnaire
- Medical Release Form
- Insurance Card (copy front/back)
- Care of Unaccompanied Minor: Consent to Treat
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: email@example.com
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:
- Print all (3) forms and fill in by hand. Then either:
- Mail to our office. Or
- Scan completed documents and email to firstname.lastname@example.org.
- 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: email@example.com
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.