Forms

Electronic Forms (Preferred Option)

Please select the appropriate patient type:

New Patient Visit

Follow-up Visit

Follow Up Old (Patient who has not been seen in 3 years)

Fetal Echocardiogram Visit

Dr. Levchuck Procedure Consultation

Medical Record Release

Click the links below to download the PDF**

(Only if you have an issue with the Online Forms)

Child Demographics (6 pages, please be as complete as possible)

New Patient Intake Form (4 pages, please be as complete as possible)

Follow Up Intake Form (2 pages, please be as complete as possible)

Adult Demographics (8 pages, please be as complete as possible)

Fetal Intake Form (3 pages, please be as complete as possible)

Spanish Demographics (7 pages, please be as complete as possible)

Medical Record Release (records sent from PCLI to another doctor) (2 pages, please be as complete as possible)

Medical Record Release (get records sent to PCLI) (2 pages, please be as complete as possible)

**To view PDF files, you must have Adobe Acrobat Reader. If you don’t already have Adobe Acrobat Reader, you can download it for free here