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Northwest Immediate Care
4332 N.Elston Rd,
Chicago, IL - 60641
Ph : 773-754-3500
Fax: 773-754-3504

Open seven days a week, 365 days a year Please call us for our current timings. Patients can Schedule an Appointment or walk in.

Not sure if you need to seek emergency care? Visit our Frequently Asked Questions area for guidance.

For information about accepted payment methods, please visit this link.

Appointment Form:

Patient Information
	First Name*:
	Middle Name:
	Last Name*:
	Gender:
Contact Information
	Contact Name (if different than patient name):
	Address*:
	City*:
	State*:
	Zip Code*:
	Telephone*:
	Email Address:
Insurance Information
	Primary Health Insurance Name:	(Please specify Other)
	Primary Health Insurance Type:
	Policy # :
	Group # :
	Primary Holder First Name:
	Primary Holder Middle Name:
	Primary Holder Last Name:
	Primary Holder Name:
	Insurance Claim Phone #:
	Secondary Health Insurance Type (if any):
	Policy # :
	Group # :
	Insurance Claim Phone #:
Appointment Information
	Primary Care Provider or Referring Physician's Name:
	Primary Care Provider or Referring Physician's Phone Number:
	Have you ever had an appointment at Northwest Immediate Care?
	Do you have a particular physician that you would like to see?
	If yes, please enter that physician's name here:
	Have you seen this physician before?
	Type of service requested:
	Reason for appointment:
Time Preference
	Day of week:	or
	Time of day:
	Additional comments:
Your appointment will be made by the time you come into the office. For additional questions about your appointment, please call the Northwest Immediate Care at 773-754-3500.

2010 Northwest Immediate Care

If you feel that you may have a life-threatening condition that requires emergency care, call "911"
or go to the nearest hospital-based emergency room.

Appointment Form:

Patient Information

Contact Information

Insurance Information

Appointment Information