Contact Us or Make An Appointment: (847) 690-1776

Forms and Checklist

For Our Patients

CORE Orthopedics & Sports Medicine has four well-respected physicians. Athletic injuries and on-the-job accidents causing minor or severe injuries are treated expertly at CORE in the office or in a hospital. Our physicians review all possible non-surgical treatment options with the patient and work closely with physical therapists and trainers in-house to get the athlete back on the playing field or the worker back to work. If surgical intervention is needed, then the latest techniques and facilities are available at four hospitals in the western suburbs of Chicago.

Patient Checklist

Please be familiar with this checklist before your office visit.

What To Wear

Patients having an examination of the Hips or Knees:
Please bring or wear shorts (without metal) for X-rays and examination.

Patients having an examination of the Shoulder or Back:
Please wear a tank top undershirt.

What To Bring

  1. If you have had an X-ray or MRI, please bring the CD or films. This is very important! X-rays taken at Alexian Brothers, St. Alexius or Good Shephard can be viewed online, but studies taken elsewhere need to be brought in at time of appointment in order to prevent rescheduling of appointments.
  2. Photo identification
  3. Insurance Card
  4. Co-payment
  5. Any patient less than 18 years of age must bring an adult who is older than 18 years of age and is either a legal guardian or a letter by the legal guardian authorizing treatment and also a copy of the parent’s driver license.
  6. Please bring your medication and past medical history list with you to your next appointment.

Patient Forms

Please fill out the following two forms before your appointment.

  1. EMR (Patient Health History) – CO – provided through Exscribe
    If you are a new patient or have not been seen in our office since January 23, 2012, please fill out the new patient form. This should take you about 20 minutes to complete. This information will automatically be sent to our system once submitted so you do not need to print it out.
  2. Privacy Notice (HIPPA Information)
    Please read this notice to understand how CORE may use and share medical information about you, to learn what your rights are as a patient and what duties CORE has regarding the use and disclosure of medical informaiton.

Authorization to Release Medical Information

Please fax all releases to 847-690-1777 Attn: Medical Records

Minor Consent

As the parent, if you are unable to attend your child’s visit, please read the Minor Consent form thoroughly and send with your child the day of the appointment.

Note: To view or print these forms, you will need Adobe Acrobat Reader.

Preparing For Your Joint Replacement Surgery

Make an Appointment Today! (847) 690-1776



Watch Video


Knee surgery Patient of Dr. Daniel Kuesis


Watch Video


Knee surgery Patient of Dr. Daniel Kuesis


Bilateral Hip Patient of Dr. Daniel Kuesis

Surgical Affiliations

Geneva Surgical Suites LLC
Geneva Surgical Suites

119 Elizabeth lane 53218 Genoa City, Wisconsin

Phone : 262-295-1213

Alexian Brothers Medical Center

800 Biesterfield Rd. Elk Grove Village, Illinois 60007

Phone : 847-437-5500

St. Alexius Medical Center

1555 Barrington Road Hoffman Estates, Illinois 60169

Phone : 847-843-2000

Advocate Good Shepherd Hospital

450 West Highway 22, Barrington, IL 60010

Phone : 847-381-0123


Make an Appointment Today! (847) 690-1776