815 459-6655
847-658-2400

Patient Forms

Please download, print and complete these forms, and bring with you to your first appointment. Click on any icon to download an Adobe Reader® file of that form.

If you don’t have Adobe Reader on your your computer, please click here for a free download.


Patient Registration Form
Authorization to Disclose Protected Health Information
Notice of Privacy Practices


Family Medicine for McHenry County  •  1095 Pingree Road, Suite 108  •  Crystal Lake, Illinois 60014
Michael Lesser, MD  •  Clare Legursky, MD
Cindy MacDonald, RN, MSN, FNP  •  Christy Benton, RN, MSN, FNP
Linda Rood, RN, BS, MSN, FNP  •  Katherine Galias, RN, MSN, APN