Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, contact our office at (312) 563-5000. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete.
Patient Registration Forms
Urologist Dr. Laurence Levine in Chicago, Illinois welcomes you to our practice. Once you have made your initial appointment, you may pre-register by downloading, printing, and completing the forms below. Completing the forms prior to your visit will help speed up the new patient registration process.
Please be sure to bring them with you to your first visit, along with any diagnostic films or other test results that may have been ordered or performed by another physician.
Downloadable Forms:
- Chronic Scrotal Content Pain Symptom Index
- Erectile Dysfunction Questionnaire
- IIEF Survey for Erectile Dysfunction
- PDQ Scale for Peyronie's Disease
- Peyronie's Disease Patient Questionnaire
- Premature Ejaculation Questionnaire
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
