Advance Pain Centers Online Forms

PCL - PTSD Checklist

PTSD Questionnaire

HIPPA Form

Authorization to Release Medical Records

Intake Form

Non-Pain Questionnaire

Please scan and email forms to:
Greg.PTSIHope@gmail.com

Or mail to:
Advance Pain Centers
Eugene Lipov, M.D.
P. O. Box 579
Hampshire, IL  60140

We thank you for helping to make the difference in the lives of suffering Americans today!

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