Welcome to the Couri Center and thank you for choosing us!

  1. Please confirm that the Couri Center is in your insurance network.  We are in many insurance plans, but since we are a private practice and not owned by any of the hospitals, it is always a good idea to confirm.
  2. Please complete the following patient forms, as applicable, and return to us.

As soon as we receive your paperwork and enter your information into our system, we will contact you right away to schedule an appointment.

We look forward to partnering in your healthcare!  Please call 309-692-6838 with additional questions or click below.

Patient Forms

New Patients - Women

New Patients - Men

  • Male Medical Forms
  • Insurance Card (copy front/back) please mail or email a copy to

Please complete and email forms to:

It is critical we receive these forms at least 24 hours prior to your appointment time. 


Print forms and fill in by hand.

  1. Scan completed documents and email to


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:


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.