For Questions or to Schedule a Consultation
Call: 844-SGB- PTSD (844-742- 7873)

To Send Completed Patient Forms
Fax 224-777- 2101

Email

 

To have the SGB procedure done by Dr. Eugene Lipov, please download and complete the forms below.

Pre-Visit Questionnaire Non-Pain H&P (required for everyone)

Pre-Visit Questionnaire (required for everyone)

Intake Form (required for everyone)

PTSD Questionnaire Pre-SGB Approval (required for everyone)

Authorization for Release of Medical Records (required for everyone)

HIPPA (required for everyone)

Civilian

Military