Patient Forms

The following downloads are forms that you will need to print out and fill in prior to your first office visit.
Printing these out and signing them before your first visit will save you time! Please feel free to call our office if you need any assistance.

Downloads

Adult Medical History Form - This form needs to be fully filled out prior to your first appointment.

Pediatric Medical History Form - This form needs to be fully filled out prior to your child's first visit with us.

AAC New Patient Info Form - This form gives us information about you. It provides us with insurance and other necessary financial information so that we can file your office charges with your insurance carrier.

AAC New Patient Financial Form - This form provides you with our financial policies.

AAC New Patient HIPPA Form - This form provides you with information about your rights to privacy and our responsibilities to you regarding the release of any of your medical information.

AAC Privacy Disclosure Form

Contact Us

5521 W. Lincoln Highway
(US 30 & Burr Street),
Suite 100
Crown Point, Indiana 46307
Phone: 219-756-6100
Fax: 219-756-6111
Click here for directions!

2802 Leonard Drive
Valparaiso, Indiana 46383
Phone: 219-531-5855
Fax: 219-531-1617
Click here for directions!

3125 Willowcreek Rd.
Portage, Indiana 46368
Phone: 219-762-3055
Fax: 219-756-6111
Click here for directions!