NEW PATIENTS The forms in this box are for new patients only.
Note: To view and print PDF files, you will need a PDF-reading program such as Adobe Reader. Most computers have a PDF reader
already installed, but if yours doesn't, you can download Adobe Reader here for free.
INTAKE FORMS If you have an appointment with Dr. Schultz for the first time, please click the
image on the left to download the intake forms. If you bring the completed
forms to your office visit, it will ensure that Dr. Schultz has the
maximum amount of time to consult with you.
PEDIATRIC INTAKE FORMS These forms are only for new patients under the age of 18.
Any pages requesting the patient's signature can be signed by either the patient or their parent/guardian.
ALL PATIENTS The forms in this box are for new patients and established patients.
Note: To view and print PDF files, you will need a PDF-reading program such as Adobe Reader. Most computers have a PDF reader
already installed, but if yours doesn't, you can download Adobe Reader here for free.
INFO RELEASE AUTHORIZATION - FROM DR SCHULTZ (OPTIONAL) Use this form to if you want to allow Dr. Schultz to release your records to you or another care provider.
NOTE: A $25 fee may apply depending on the number of records and their destination. Contact us to find out if this fee applies for your request.
ESTABLISHED PATIENTS The forms in this box are for patients who have already had a consultation with Dr. Schultz.
Note: To view and print PDF files, you will need a PDF-reading program such as Adobe Reader. Most computers have a PDF reader
already installed, but if yours doesn't, you can download Adobe Reader here for free.
SUPPLEMENT LETTER REQUEST You may use this form to request that Dr. Schultz write a letter of medical necessity for any nutritional supplements you've purchased, so that they can be covered under your flex spending benefits, if applicable. You may fill out the form and email it to us at patientcare@drfredschultz.com, fax it to us at (630) 933-9724, mail it, or drop it off in person. Thank you.
PRESCRIPTION MEDICATIONS Please download and fill out this form, listing all medications you are currently taking that have been prescribed by physicians other than Dr. Schultz. You can bring this list to your appointment, email it to us at patientcare@drfredschultz.com, or fax it to us at (630) 933-9724. Thank you.
NUTRITIONAL SUPPLEMENTS Please download and fill out this form, listing all
supplements you are currently taking,whether recommended by Dr. Schultz, self-prescribed, or prescribed by physicians other than Dr. Schultz. You can
bring this list to your appointment, email it to us at patientcare@drfredschultz.com, or fax it to us at (630) 933-9724. Thank you.
ESTABLISHED PATIENT UPDATE PACKET If you are an established patient of Dr. Schultz' who hasn't been in for a consultation in the past year, please fill out these forms so that we can update your file.
ESTABLISHED PATIENT UPDATE PACKET - PEDIATRIC If you/your child is an established patient of Dr. Schultz' under age 18 who hasn't been in for
a consultation in the past year, please fill out these forms so that we
can update your file.
Integrative medicine. The intelligent blend of conventional and natural approaches to wellness. (630) 933-9722 Center for Health and Healing Fred Schultz MD FAAFP 2150 Manchester Rd Wheaton IL 60187
